Lu. 


THE 


TREATMENT    OF    WOUNDS 


ITS 


I  BY 

LEWIS  S.  P1LCHEK,  A.M.,  M.D. 

MEMBER   OF  THE   NEW  YORK   SURGICAL   SOCIETY 


WITH  ONE  HUNDRED  AND  SIXTEEN  WOOD  ENGRAVINGS 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

56  &  58  LAFAYETTE  PLACE 
1883 


0^700 


OOPTBIOHT 

WILLIAM   WOOD  &  COMPANY 
1883 


TROW'S 

PRINTING  AND  BOOKBINDING  COMPANY 

201-213  East  Twelfth  Street 

NBW  YORK 


PREFACE. 


IN  the  present  work  I  have  attempted  to  state,  first,  the  principles 
upon  which  the  treatment  of  wounds  should  be  based  ;  then,  to  de- 
scribe the  means  which  are  available  to  the  surgeon  for  satisfying 
the  demands  of  these  principles ;  and,  lastly,  to  point  out  the  parti- 
cular modifications  which  the  peculiarities  of  special  wounds  may 
require.  In  the  first  part  of  the  work,  the  physiology  of  repair,  and 
the  character  of  the  influences  which  are  capable  of  disturbing  physio- 
logical repair  necessarily  receive  attention.  A  knowledge  of  these 
must  form  the  ground-work  of  all  rational  wound-treatment.  As  the 
result  of  the  more  exact  methods  of  research  of  recent  years,  while 
much  chaff,  consisting  of  half  truths  and  incorrectly  interpreted  obser- 
vations, has  accumulated,  some  facts  have  undeniably  been  established, 
in  the  domain  of  physiology  and  pathology,  which  will  stand  the  win- 
nowing process  of  time  and  experience,  and  will  remain  as  permanent 
truths  that  will  always  require  the  recognition  of  intelligent  students 
of  Nature.  Not  the  least  of  these  are  those  which  have  appeared  in 
the  special  fields  of  wound-repair  and  wound-disturbance.  These  I 
have  endeavored  to  state  in  the  following  pages  with  an  earnest  con- 
viction of  their  truth,  and  of  the  great  importance  attaching  to  their 
becoming  generally  understood  and  accepted  as  working-facts. 

It  is  not  necessary  that  one  should  blindly  follow  the  theories  or 
the  methods  of  any  one  man  ;  nor,  indeed,  is  it  just  to  select  any  one 
name  as  the  special  representative  of  the  present  state  of  the  science 
or  the  art  of  wound-treatment.  The  advances  in  our  knowledge  of 
the  therapeutics  of  wounds,  which  it  would  be  criminal  on  the  part  of 
a  surgeon  of  to-day  to  ignore,  are  the  results  of  the  labors  of  many 


IV  PREFACE. 

men,  in  many  different  fields.  In  the  present  work,  I  have  aimed  to 
give  credit  in  the  proper  connection,  in  the  body  of  the  work,  to  the 
various  sources  from  which  material  has  been  drawn  for  its  pages.  In 
this  place,  however,  an  opportunity  is  afforded  for  me  to  acknowledge 
my  indebtedness  to  my  friend,  Prof.  Roswell  Park,  of  Buffalo,  for 
special  assistance  in  the  preparation  of  the  chapter  on  Wounds  of  the 
Head,  and  to  my  colleagues,  Drs.  Geo.  R.  Fowler,  Jas.  E.  Pilcher, 
and  Glen.  R.  Butler,  for  many  helps  rendered  in  the  course  of  my 
work. 

LEWIS  S.  PILCHER. 

4  MOKKOE  STBEET,  BROOKLYN,  N.  Y., 
August,  1883. 


CONTENTS. 
PART  I. 

IN     OENERAL 


SECTION  I. 
THE  PRINCIPLES   OF    WOUND-TREATMENT. 

CHAPTER  I. 
GENERAL  CONSIDERATIONS  ON  WOUNDS. 

PAGES 

Importance  of  Wound-Treatment — Modern  Methods  of  Surgical  Study — Contro- 
versies on  Wound-Treatment  One  Hundred  Years  Ago — John  Bell — O'Hal- 
leran — Principles  of  Wound-Treatment  Analyzed — Definitions — Classification 
— Influences  that  Modify  the  Healing  of  Wounds 3-20 

CHAPTER  II. 

THE  IMMEDIATE  EFFECTS  OF  WOUNDS  IN  GENERAL— THE    RE- 
PAIR OF  WOUNDS— INFLAMMATION. 

Constitutional  Effects — Shock — Reaction — Traumatic  Fever — Local  Effects — Im- 
pairment of  Function — Gaping — Pain — Haemorrhage —Active  Hyperasmia— 
Union  of  Wounds — Exudation — Vascularization — Connective-tissue  Trans- 
formation— Cicatrization — Union  by  First  Intention — Causes  of  Modified 
Repair — Defects  of  Apposition — Defects  of  Protection — Defects  of  Nutrition — 


VI  CONTENTS. 

PAGES 

Modified  Normal  Repair — Healing  by  Granulation— Healing  by  Secondary 
Adhesion— Healing  by  Scabbing — Suppuration — Disposition  of  Effused  Blood 
and  Dead  Tissue — Destructive  Disturbances  of  Repair — Inflammation — In- 
fectious Wound- Diseases. ...  21-36 


CHAPTER  III. 

THE   RELATIONS  OF    MICRO-ORGANISMS  TO    WOUND-DISTURB- 
ANCES. 

Results  of  Defects  of  Protection — Causes  of  Decomposition  of  Animal  Tissues — 
Researches  of  Pasteur  and  Tyndall — Atmospheric  Organisms — Resisting 
Power  of  Living  Tissues — Species  and  Generation  of  Micro-organisms — 
Bacteria — Bacilli — Micrococci-- Researches  of  Ogston,  Koch  and  others — 
Views  of  Hunt — Summary — Wound -Suppuration — Septicaemia — Pyasrnia — 
Micrococcus-poisoning — Clinical  Demonstrations — Results  of  the  Practice  of 
Lister,  Volkmann,  and  Nussbaum — Comparative  Statistics  of  Amputations — 
Macewen's  Osteotomies — Testimony  of  Sands,  Stokes,  Cheyne,  and  Little — 
Resume , .  37-59 


CHAPTER  IV. 
ASEPSIS  AND  ANTISEPSIS— WOUND-CLEANLINESS. 

The  Scientific  Basis  of  Wound -Treatment — Ptomaines — Sepsis — Asepsis — Anti- 
sepsis— Cleanliness — Primary  Cleansing  of  a  Wound — Drainage — Cleanliness 
of  Adjacent  Tissues — Cleanliness  of  Wound-Dressings — Air-Purification — 
Antiseptic  Sprays — Practice  of  Lister — Experiments  of  Stimson  and  Duncan 
—Effects  of  Sprays 60-68 

CHAPTER  V. 

WOUND-DISINFECTION—ANTISEPTICS. 

Antiseptics  in  General : — Comparative  Germicidal  Strength  of  Various  Agente — 
Strengths  Required  to  Restrain  Germ-Development — Local  Effect  of  Anti- 
septics on  Tissues — General  Toxic  Effects.  Special  Antiseptics; — Corrosive 
Sublimate — Permanganate  of  Potassa — Carbolic  Acid — Its  Advantages — Its 
Disadvantages — Carbolic  Intoxication — Chloride  of  Zinc — Salicylic  Acid — 
Boracic  Acid — Acetate  and  Aceto-Tartrate  of  Alumina — Iodine  and  lodo- 
form— lodoform  Intoxication — Xaphthalm — Subnitrate  of  Bismuth 69-00 


CONTENTS.  VI 1 

SECTION  II. 

THE  PKACTICE   OF  WOUND-TREATMENT. 
CHAPTER  VI. 

THE  AEEEST   OF  H^EMOEEHAGE. 

PAGES 

Spontaneous  Hamostasis — Surgical  Ilcemostasis — Exposure  to  Air— Cold — Hot 
Water — Iodine — Alcohol — Turpentine — Mechanical  Pressure  —  Compresses — 
Tampons — Acupressure — Forcipressure — Ligation — Catgut  Ligatures — Plug- 
ging Vessels — Torsion — Coagulants — The  Cautery — Interrupting  Blood-current 
— Position — Forced  Flexion — Digital  Compression— Tourniquets — Elastic 
Bandage — Acupressure — Ligation — Cardiac  Sedatives 93-127 

CHAPTER    VII. 
THE   GENEEAL   CONDITION  OF  THE  PATIENT. 

Shock — Ancemia — Auto-transfusion — Transfusion — Direct  Transfusion — Defibrina- 
tion  of  Blood — Technique  of  Transfusion  — Dangers  of  Transfusion — Peritoneal 
Transfusion 128-137 

CHAPTER    VIII. 
THE  CLEANSING  OF  THE  WOUND. 

Hcemostasis — Sponging — Purification  of  Sponges — Irrigation — Continuous  Sub- 
mersion— Irrigating  Fluids — Drainage — Natural  Drainage— Artificial  Drain- 
age— Drainage-Tubes — Ab?orbable  Tubes  of  Neuber,  of  Macewen — Capillary 
Drainage — Catgut  Drains — Horse-hair  Drains — Spun-glass  Drains — -General 
Considerations  as  to  Artificial  Drains — Resume — Primary  Drainage — Second- 
ary Drainage — Accessory  Means  of  Wound- cleanliness — Adjacent  Skin — The 
Surgeon  and  his  Assistants — Instruments  and  Appliances — Compresses  and 
Protective  Appliances — Purification  of  the  Air— Spray  Producers —  Cleansing 
Septic  Wounds — Curettes — Disinfecting  Lotions 138-150 

CHAPTER  IX. 

• 

APPOSITION  OF  THE  WOUND-SUEFACES. 

Position — Bandaging— Rollers — Compresses — Adhesive  Plaster— Icthyocolla  Plas- 
ter— Gold-beater's  Skin — Collodion — Application  of  Adhesive  Bandage — Ob- 


Vlll  CONTENTS. 

PAGES 

jectionsto  Adhesive  Bandages — Suturing — Needles — Needle-holders — Thread 
— Silk — Catgut — Silk-worm-gut — Horse-hair — Metal  Wire — Application  of  the 
Suture — Stitches  of  Coaptation,  of  Approximation,  of  Relaxation — Knot- 
ting— Removing  the  Stitches—  Classification  of  Sutures — Interrupted — Con- 
tinuous— Pin — Quill — Bead — Button — Resume 160-183 


CHAPTER  X. 

PROTECTION   AGAINST    DISTURBANCES    OF    HEALING— ANTISEP- 
TIC DRESSINGS. 

Cotton  Wool—  Borated  —  Salicylated — Carbolated  —  Sublimate..— /odof  ormized  — 
Bismuth —  Gauze — Carbolated — lodof  ormized — Naphthalinated — Lint—  Tow — 
Oakum— Naphthalinated  Oakum — Jute — Turf -Mould —  Charcoal — Aluminated 
Charcoal — Sand — Sublimated  Sand — Coal  Ashes — Sawdust —  Wood-  Wool — The 
Protective — The  External  Impermeable  Envelope — Bandages — The  Metlwd  of 
Lister — The  lodoform  Dressing  of  BiUroth — EsmarcKs  Turf-Mould  Dress- 
ing 184-204 

CHAPTER  XL 

PROTECTION  AGAINST  DISTURBANCES  OF  HEALING— (CONTINUED). 

REST. 

Position  —  Compression  —  Immobilization  —  Wire-gauze  Splints  —  Plaster-of -Paris 
Splints— Shells  —  Encircling  Plaster-bandage  —  Fenestrated — Interrupted — 
Combined — Change  of  Dressings — Anodynes 205-217 

CHAPTER  XII. 

THE  RELIEF  OF  DISTURBANCES  OF  HEALING— INFLAMMATION- 
GANGRENE— ERYSIPELAS— SEPTIC^IMIA. 

Treatment  of  Inflammation — Opening  the  Wound — Incisions — Removal  of  For- 
eign Bodies — Position — Compression — Reduction  of  Heat— Gold  Compresses — 
Evaporating  Lotions — Irrigation — Immersion — Ice-bags — Cold  Water  Coils — 
Relaxation  of  Vessels — Abstraction  of  Blood — Interrupting  the  Blood-supply — 
Resume — Treatment  of  Gangrene — Incisions — Continuous  Antiseptic  Irriga- 
tion— Stimulants — Treatment  of  Erysipelas — Antiseptics — Subcutaneous  In- 
jections of  Carbolic  Acid — Superficial  Applications — Naphthalin — Tonics  and 
Stimulants— Antiphlogistics — Treatment  of  Septiccemia — Local  Disinfection — 
General  Treatment. .  .  218-333 


CONTENTS.  IX 


PART  II. 

SPECIAL     WOUNDS 


SECTION  I. 

VAKIETIES    THAT    MAY    OCCUR    IN    ANY    PART    OF 

THE  BODY. 

CHAPTER  XIII. 

SUBCUTANEOUS    WOUNDS— INCISED  WOUNDS— CONTUSED 
WOUNDS— LACEEATED   WOUNDS. 

PAGES 

Subcutaneous  Haemorrhage — Restriction  and  Absorption  of  Effusions— Massage — 
Dry  Cupping — Sorbef acients — Inflammation — Incised  Wounds — Rest —  Con- 
tused and  Lacerated  Wounds — Peculiarities — Secondary  Haemorrhage — Pri- 
mary Cleansing — Drainage — Necrosis  of  Tissue — Coaptation — Period  of  Gran- 
ulation— Contused  Punctured  Wounds — Incisions 237-240 

I 

CHAPTER   XIY. 
GUNSHOT  WOUNDS. 

Peculiarities  of  Gunshot  Wounds  —  Haemorrhage —  Wound -cleanliness — Imme- 
diate Antiseptic  Occlusion — No  Immediate  Exploration — Classification — Sta- 
tistics of  Reyher — Non-occlusive  Treatment — Enlargement,  Cleansing,  and 
Disinfection — Probes  and  Probing — Removal  of  Bullets — Immobilization.  247-254 

CHAPTER  XV. 

EXTERNAL    WOUNDS    COMMUNICATING    WITH    FRACTURES    OF 
BONES  AND    WITH   JOINT-CAVITIES. 

Peculiarities — Value  of  Antiseptic  Methods  of  Treatment— MacCor mac — Classifi- 
cation— Recent  Injuries  with  Slight  External  Wound — Primary  Antiseptic 
Occlusion — Recent  Injuries  with  External  Wound  of  Considerable  Extent — 


CONTENTS. 

PAGES 

Primary  Exploration  and  Cleansing— Counter- incisions — Splinters  of  Bone — 
Drainage — Suture —  Wounds  of  Joints — Incisions — Partial  Resections — Protec- 
tive Dressings — Immobilization — After-treatment — Injuries  not  Recent  and 
Septic — Favorable  Cases — Cases  with  Pronounced  Septic  Infection — Disin- 
fection— Immobilization — Fenestrated  and  Interrupted  Plastic  Splints — Hon- 
eycomb Plaster  Splint 255-266 


SECTION   II. 

WOUNDS   OF  TISSUES    COMMON  TO  ALL  PAETS   OF 

THE  BODY. 

CHAPTEK    XVI. 
WOUNDS  OF  MUSCLES— TENDONS— NEEVES. 

Wounds  of  Muscles — Difficulties  of  Coaptation — Position — Bandaging — Suturing 
— Rest — Protection  from  Sepsis — Subcutaneous  Ruptures —  Wounds  of  Ten- 
dons— Healing  of  Subcutaneous  Wounds — Difficulties  of  Open  Wounds — Im- 
portance of  Antisepsis,  Protection,  and  Rest — Suturing  Tendons — Lange's 
Case — Pauly's  Case —  Wounds  of  Nerves — Importance  of  Approximation  of 
Divided  Ends — Methods  of  Approximation — Suturing  Nerves — Tillman's 
Statistics— Results  reported  by  Page— Pye's  Case — Page's  Case — Application 
of  the  Nerve-suture — Direct  Nerve-suture — Peri-neural  Sutnre — The  Suture 
Material — Conditions  Requiring  Nerve-suture — Neuroplasty — Tubular  Suture 
— Centra-indications — Requisites  to  Success 269-279 

CHAPTER  XVII. 

• 

WOUNDS  OF  BLOOD-VESSELS. 

Importance  of  Wounds  of  Blood  vessels — Results  to  be  Secured  in  Treatment — 
Difficulties— Obliteration  of  Vessels— Relations  of  Coagnlum  to  Repair — Phys- 
iology of  Repair — Apposition  of  Inner  Serous  Surfaces — Means  of  Compres- 
sion— The  Ligature — Ligation — Gross  on  Immoderate  Violence  in  Tying  a 
Ligature — Rules  of  Procedure — Complications  of  Wounds  of  Blood-vessels — 
Primary  Haemorrhage — Intermediary  Haemorrhage — Secondary  Haemorrhage 
— Diffuse  Traumatic  Aneurism —  Wounds  of  Veins — Peculiarities — Phlebitis 
and  Periphlebitis — Thrombosis — Effects  of  Septic  Ligatures — Acupressure 
and  Forcipressnre— J.  E.  Pilcher's  Case — Advantages  of  Aseptic  Ligatures — 
Repair  of  Vein  Wounds— Gross'  Case — Langenbeck's  Case — Lateral  Ligation — 
Braun's  Statistics — Necessary  Precautions  —Lateral  Suture 280-298 


CONTENTS.  XI 

SECTION  III. 
WOUKDS  OF  SPECIAL  REGIONS. 

CHAPTER  XYIII. 
WOUNDS  OF  THE  HEAD. 

PAGES 

Anatomical  Considerations — Superficial  Wounds  of  Scalp — Bruises  and  Contusions 
— Punctured  and  Incised  Wounds — Extensive  Lacerations — Superficial  Gun- 
shot Wounds — Deep  Wounds  of  Scalp  with  Injuries  to  the  Cranium — Signs  of 
Compression  of  Brain  Absent — Fractures  of  the  Skull — Indications  for  Tre- 
phining— Fractures  of  the  Base  of  the  Skull — Compression  of  the  Brain — 
Wounds  of  Intra-cranial  Vessels  and  Sinuses — Injuries  to  Cranial  Nerves — 
Wounds  of  Brain  Substance — Hernia  Cerebri — Wounds  during  Birth — Band- 
aging the  Head — Trephining — Indications  for  the  Operation — Operative 
Technique — Excision  of  Irregular  Fragments — Wounds  of  Eye  —  Wounds  of 
Internal  Ear— Wounds  of  the  Face—  Wounds  of  the  Mouth 301-332 

CHAPTER    XIX. 
WOUNDS  OF  THE  NECK  AND  OF  THE  THOEAX. 

Wounds  of  the  Larynx  or  Trachea — Punctures — Longitudinal  Wounds — Trans- 
verse Wounds — Suturing  the  Trachea — Antisepsis — Tracheal  Canula — Intra- 
tracheal  Polypi — Haemorrhage  into  Trachea —  Wounds  of  Pharynx  or  (Esoph- 
agus— Swallowing  Interdicted — CEsophageal  Tube — Primary  Importance  of 
Deep  Union — Longitudinal  Wounds — Gunshot  Wounds — Transverse  Wounds 
—  Wounds  of  the  Great  Vessels  of  the  Neck — Arteries — Vertebral  Arteries — 
Internal  Jugular  Vein — Lateral  Ligature — Cases  of  Parkes,  Allis,  Gerster, 
Lange,  Lidell,  and  J.  E.  Pilcher — Non-penetrating  Wounds  of  the  Thorax — 
Wounds  of  Internal  Mammary  and  Intercostal  Arteries — Penetrating  Wounds 
of  the  Thorax — Heart  and  Pericardium — Lungs — Pleurae — Haemothorax — 
Pneumothorax — Emphysema — Empyemaand  Hydrothorax — Resume. . . .  333-350 

CHAPTER  XX. 
WOUNDS  OF  THE  ABDOMEN— OF  THE  PELVIS. 

Non-penetrating  Wounds  of  Parietes — Arrest  of  Haemorrhage — Apposition — Pene- 
trating Wounds  without  Injury  to  Viscera — The  Peritoneal  Wound — Pro- 
trusion of  Viscera  —  Intestine  —  Omentum  —  Other  Viscera  —  Penetrating 


Xll  CONTENTS. 

PAGES 

Wounds  with  Injury  to  Viscera — Exploration  of  Abdomen — Diagnosis  Positive 
— Diagnosis  Presumptive — Arrest  of  Intra-peritoneal  Haemorrhage — Suture  of 
Visceral  Wounds — Lembert's  Suture — Jobert's — Emmert's — Gely's — Gussen- 
bauer's — Czerny's — The  Continuous  Intestinal  Suture — Circular  Invagination 
Suture — Primary  Cleansing  of  Peritoneal  Cavity— Drainage — Peritonitis  and 
Septicaemia —  Wounds  of  the  Bladder — External  Incisions — Laparotomy — Sut- 
ure of  Bladder — Catheterization —  Wounds  of  Anut  and  Rectum 351-374 


CHAPTER  XXL 
WOUNDS  OF  THE  EXTREMITIES— AMPUTATION. 

Limitations  of  Conservation — Classification  of  Wounds  possibly  demanding  Am- 
putation— Duty  in  Doubtful  Cases — Period  for  Amputation — Primary,  Inter- 
mediary, and  Secondary  Periods  defined — Effect  of  Antiseptics  to  prolong 
Primary  Period — Shock  a  Centra-indication — Amputation  to  be  done  during 
Primary  Period — Point  of  Amputation — Treatment  of  the  Amputation 
Wound. 375-378 

INDEX..  .  379-391 


PART  I. 

IN     OEZSTERAL 


SECTION  /. 

THE  PRINCIPLES  OF   WOUND-TREATMENT. 


THE 


TREATMENT   OF   WOUNDS. 


CHAPTER   I. 
GENEEAL  CONSIDEEATIONS  ON  WOUNDS. 

Importance  of  Wound-Treatment — Modem  Methods  of  Surgical  Study — Controversies 
on  Wound-Treatment  One  Hundred  Years  Ago — John  Bell — O'Hallerans — Prin- 
ciples of  Wound- Treatment  Analyzed — Definitions— Classification — Influences  that 
Modify  the  Healing  of  Wounds. 

*'  THE  treatment  of  wounds  is  undoubtedly  not  merely  the  first  stone, 
but  also  the  corner-stone  of  surgery.  By  it  surgery  has  attained  its 
greatest  triumphs  ;  by  it  our  branch  of  the  profession  has  conferred  its 
greatest  benefits  on  mankind  ;  by  it  each  individual  surgeon  may  hope  to 
do  more  good  than  in  any  other  way.  Nevertheless  it  has  ever  been  one 
of  the  opprobria  of  surgery  ;  though  it  was  the  first  work  in  which  sur- 
geons were  engaged,  it  is  at  the  present  day  one  of  the  chief  questions  of 
surgery,  and  I  trust  it  will  remain  so  till  it  has  attained  to  perfection." 

These  words  by  Professor  George  M.  Humphrey,  in  the  Surgical  Sec- 
tion of  the  International  Medical  Congress  of  London,  in  1881,  do  not  too 
strongly  set  forth  the  importance  of  the  subject  of  the  treatment  of  wounds. 
It  has  been  too  much  considered  the  highest  exerciss  of  the  skill  of  the 
surgeon  to  make  wounds,  and  the  deftness  and  neatness,  perhaps  the 
brilliancy,  with  which  the  mere  mechanical  portions  of  the  surgeon's  work 
may  be  done  have  been  considered  as  more  important  evidence  of  merit 
than  the  less  striking  and  more  prolonged  duties  required  in  the  after- 
treatment,  in  the  course  of  which  his  judgment  and  the  resources  of  his 
science  are  continually  being  put  to  their  highest  test.  Not  only  is  this 
due  in  great  measure  to  the  fact  that  the  awe  and  admiration  with  which 


4  THE   TREATMENT    OF    WOUNDS. 

the  laity  look  upon  the  deliberate  wounds  which  are  made  by  a  surgeon, 
clothe  such  procedures  with  undue  importance  ;  but  it  is  also  fostered  by 
the  improper  methods  of  surgical  instruction,  so  generally  pursued,  in 
which  the  chief  interest  is  made  to  centre  upon  the  operative  procedures, 
and  little  or  no  attention  is  directed  to  the  details  of  dressing  and  after- 
treatment. 

It  may  be  considered  as  one  of  the  best  evidences  of  the  solid  charac- 
ter of  the  advancement  which  is  claimed  for  the  surgery  of  to-day,  that  in 
its  discussions  and  in  its  practice  the  principles  of  wound-treatment  have 
attained  an  overshadowing  importance,  while  the  mechanical  details  of 
operative  surgery  have  been  relegated  to  a  minor  place. 

That  which  has  contribiited  to  this  end  most  especially  is  the  applica- 
tion to  surgery  of  the  rigid  experimental  methods  of  investigation  of 
modern  Science,  by  which  general  impressions,  formed  from  imperfectly 
noted  or  understood  experience,  have  been  substituted  by  exact  demon- 

s 

strations,  guarded  by  adequate  checks  and  careful  precautions,  that  serve 
also  to  emphasize  the  limitations  and  variations  in  the  applications  of  the 
principles  which  they  demonstrate. 

"While  surgery  has  thus  always  been  a  noble  art,  it  may  therefore  now 
begin  to  claim,  for  the  first  time  with  some  justice,  that  it  is  a  noble 
science. 

John  Bell,  in  his  delightful  discourses  on  the  "  Nature  and  Cure  of 
Wounds"  (Edinburgh,  1795),  claims  that  the  surgeon  "does  all  his  ser- 
vices by  observing  and  managing  the  properties  of  the  living  body  ;  where 
the  living  principle  is  so  strong  and  active  in  every  pail  that  by  that 
energy  alone  it  regenerates  the  lost  substances,  or  reunites  in  a  more 
immediate  way  the  more  simple  wounds."  The  picture  which  Bell  pro- 
ceeds to  give  of  the  opinions  and  discussions  among  the  surgeons  of  his 
day,  which  is  barely  one  hundred  years  ago,  as  to  the  treatment  of  wounds, 
is  almost  a  burlesque  upon  what  is  taking  place  at  the  present  day,  with  a 
change  only  in  the  particular  points  of  discussion. 

"Thirty  years  ago, "he  says,  "  surgeons  had  no  settled  notions  that  cut 
surfaces  might  be  made  to  adhere  ;  they  had  no  motive  for  saving  the 
skin  ;  or  where  they  had  saved  it,  they  did  not  know  how  it  should  be 
used,  nor  how  much  it  might  contribute  to  a  speedy  cure  ;  if  they  extir- 
pated a  tumoi-,  they  cut  away  along  with  it  all  the  surrounding  skin  ;  if 
they  performed  the  trepan,  they  performed  in  a  most  regular  manner  that 
preliminary  operation  which  they  chose  to  call  scalping  ;  or  in  plain 


IN    THE    EIGHTEENTH    CENTURY.  5 

terms,  they  cut  away  six  or  eight  inches  of  that  skin  which  should  have 
saved  the  fractured  skull  from  exfoliation,  and  should  have  immediately 
covered  and  defended  the  brain  ;  in  performing  amputation,  they  cut  by 
one  stroke  down  to  the  bone  ;  and  even  when  they  performed  the  flap 
amputation  they  dressed  their  stump  and  flap  as  distinct  sores. 

"  An  exfoliation  of  the  bone  in  these  older  operations  was  a  thing  un- 
avoidable ;  so  that  it  was  part  of  their  art  and  skill  to  procure  exfoliation. 
And  the  filling  up  and  final  healing  of  their  conical  stump  was  so  slow  a 
process,  so  imperfect,  and  so  many  exfoliations  of  the  bone,  with  other 
lets  and  hindrances,  intervened,  that  it  is  no  wonder  their  imagination  was 
so  much  occupied  about  the  digesting,  incarning,  and  cicatrizing  of 
wounds.  Whenever  a  bone  was  laid  bare,  they  believed  that  it  must  ex- 
foliate before  it  could  heal ;  until  they  saw  this  exfoliation  perfect,  till  the 
bone  had  at  least  thrown  off  an  outer  scale,  they  would  not  permit  it  to 
heal ;  they  would  not  lay  the  skin  down  upon  a  wound  upon  the  shin- 
bone,  or  if  there  was  a  lacerated  scalp,  they  cut  the  torn  piece  off ;  a 
large  part  of  the  scalp  could  not  be  regenerated  in  less  than  several  weeks 
or  months  ;  and  so  they  made  good  their  opinion  by  their  practice  ;  for 
very  generally,  in  that  space  of  time,  the  whole,  or  a  part  at  least,  of  the 
exposed  bone,  was  thoroughly  spoiled.  These  were  a  few  of  the  many 
mistakes  committed  daily  by  the  older  surgeons,  who  were  contented  with 
their  theories  about  incarning  and  cicatrizing  of  wounds,  too  proud  of 
their  own  art  and  too  little  inclined  to  follow  the  simple  ways  of  nature.'' 

The  subject  upon  which  discussio"n  ran  high  in  Bell's  time  was  that  of 
procuring  the  repair  of  wounds  by  immediate  adhesion.  The  French  sur- 
geons had  declared,  not  only  that  their  flap  amputation  procured  an  easy 
and  perfect  cure,  but  they  affirmed  that  often  in  three  days  the  flesh  of 
such  a  stump  had  adhered.  To  this  a  contemporary  of  Bell,  O'Hallerau, 
whom  Bell  characterizes  as  an  excellent  and  most  judicious  surgeon, 
whose  doctrine  and  practice  was  followed  by  all  the  best  surgeons  of 
that  day,  had  replied  :  "I  would  ask  the  most  ignorant  tyro  in  our  pro- 
fession whether  he  ever  saw,  or  heard  even,  of  a  wound,  though  no  more 
than  one  inch  long,  united  in  so  short  a  time  ; "  adding,  "  these  tales  are 
told  with  more  confidence  than  vei-acity  ;  healing  by  inosculation,  by  thu 
first  intention,  by  immediate  coalescence  without  suppuration  is  merely 
chimerical  and  opposite  to  the  rules  of  nature." 

The  field  of  controversy  has  shifted  since  that  day,  but  human  nature 
has  remained  the  same,  and  the  same  disinclination  to  accept  doctrines 


6  THE   TREATMENT    OF    WOUNDS. 

which  do  not  agree  with  preconceived  notions,  or  that  seem  to  be  opposed 
to  particular  experience,  characterize  the  discussions  of  the  present  day. 
Many  of  the  differences  that  have  ever  existed,  or  do  still  exist,  have  arisen, 
however,  from  the  tendency  to  make  theoretical  considerations  or  indi- 
vidual experience,  the  elements  of  which,  have  not  been  accurately  ana- 
lyzed and  considered,  the  basis  of  generalizations  that  are  esteemed 
comprehensive.  It  is  not  surprising  that  a  catholic  and  philosophical 
student  of  the  subject  of  wound  treatment,  as  he  reflects  upon  the  chang- 
ing views  and  methods  of  the  past,  as  he  observes  the  improving  results 
attained  by  differing  methods  to-day  ;  and  as  he  remembers  the  changes 
in  his  own  views  and  practice  at  various  stages  of  his  experience,  should 
hesitate  to  consider  that  the  last  step  attained  has  accomplished  that  per- 
fection which  is  the  ideal  to  be  striven  for.  Nevertheless  no  one  will  deny 
that  there  do  exist  ultimate  facts,  as  to  the  methods  by  which  the  repair 
of  injury  is  accomplished  by  living  tissues  and  as  to  the  nature  of  those 
influences,  which  may  favor  or  hinder  these  reparative  processes,  and  that 
these  facts,  when  fully  understood,  will  afford  a  sure  basis  upon  which  to 
build  a  perfect  system  of  wound  treatment. 

Nor  will  it  be  asserted,  in  the  light  of  the  experience  of  to-day,  that  it 
is  too  much  to  expect  that  scientific  research  may  accomplish  the  satisfac- 
tory and  distinct  resolution  of  the  problems  involved  in  the  search  for 
these  facts,  and  establish  them  clearly  and  indisputably.  Just  in  measure 
as  this  clear  and  indisputable  establishment  of  these  fundamental  facts  is 
being  accomplished,  does  the  treatment  of  wounds  become  emancipated 
from  theory  and  prejudice,  and  becomes  established  upon  a  final  and 
perfect  basis.  The  varying  conditions  that  attend  wounds,  conditions  of 
constitution,  of  environment,  of  structure  wounded,  of  agent  and  manner 
of  wound,  the  presence  or  absence  of  needed  material  for  treatment,  and 
the  measure  of  perfection  in  the  care  which  may  possibly  be  given  to  the 
wound  will  ever  be  the  unknown  and  variable  quantities  that  will  test  the 
judgment  and  skill  of  the  surgeon  in  the  application  of  principles  to 
practice. 

The  principles  of  rvound  treatment,  then,  are  of  the  highest  importance 
as  preliminary  to  the  adoption  of  rational  methods  of  practice,  and  by 
their  study  only  can  any  steady  and  permanent  advance  in  wound  thera- 
peutics be  made. 

In  recognition  of  this,  in  the  discussion  of  the  treatment  of  wounds  to 
which  the  present  work  is  devoted,  there  will  first  be  considered  the 


PLAN    OF    STUDY DIFTNTFIONS.  7 

principles  upon  which  treatment  should  be  founded,  and  from  this  it  will 
be  possible  to  proceed  to  the  application  of  these  principles  in  the  choice 
of  methods  to  be  adopted  in  practice.  The  plan  of  such  a  study  will 
include  : 

First. — The  immediate  effects  of  a  wound  upon  living  tissues. 

Second. — The  processes  instituted  by  nature,  when  undisturbed,  for 
the  repair  of  the  injury. 

Third. — Possible  sources  of  disturbance,  and  their  effects  upon  the 
natural  reparative  processes. 

Fourth. — The  means  by  which  the  natural  reparative  processes  may  be 
most  effectually  favored  and  the  action  of  disturbing  agents  may  be 
minified. 

Before  proceeding  with  this  study,  certain  further  general  considera- 
tions  should  be  noticed.  These  include  matters  of  definition,  of  classifi- 
cation, and  of  the  modifying  influences  of  a  general  character  that  affect 
the  repair  of  wounds. 

DEFINITIONS. — A  wound  is  a  division  of  continuity  of  the  bodily  tex- 
ture, produced,  either  directly  or  indirectly,  by  sudden  mechanical  force. 
Wiseman,  "the  Father  of  English  surgery,"  limits  the  use  of  the  term 
wound  to  injuries  involving  division  of  the  skin.  In  his  "  Chirurgicall 
Treatises  "  (1676),  p.  331,  he  thus  discourses  :  "  A  wound  is  a  Solution 
of  continuity  in  any  Part  of  the  body  suddenly  made,  by  anything  that 
cuts  or  tears,  with  a  division  of  the  Skin.  This  Definition  differs  much 
from  what  is  usually  delivered  by  Authors  ;  and  it  is  fit  it  should.  For 
they  generally  defining  a  Wound  by  a  Solution  in  parte  molli,  do  thereby 
exclude  a  Cut  made  into  a  Bone,  as  that  into  the  Cranium  by  a  Pole-axe, 
etc.,  which  why  it  should  not  be  called  a  Wound  I  know  not.  I  say,  it  is 
made  by  anything  that  cuts  or  tears.  Other  Authors  define  it  to  be  made 
by  an  external  Instrument,  etc.  How  then  do  they  call  that  fracturam 
cum  vulnere,  a  Fracture  with  a  Wound,  where  the  Bone  from  within 
makes  the  Wound,  and  thrusts  itself  quite  through  the  Flesh.  Hennertus 
adds  to  his  definition,  that  it  is  to  be  done  a  re  secante  and  acute :  yet  he 
reckons  those  for  Wounds  that  are  made  by  Bullets,  although  it  be  a 
Cannon-shot.  I  do  therefore  think  it  fit  to  make  my  Definition  more  com- 
prehensive, and  to  take  in  whatsoever  makes  a  sudden  Solution  of  con- 
tinuity, at  least  immediately  and  by  itself,  on  what  Part  soever  it  lighteth. 
So  a  Cut  into  a  Bone  is  a  Wound.  Tearing  the  Flesh,  Xerve,  Sinew, 
Tendon,  or  Cartilage,  by  Bullet,  Stone,  Splinter,  etc.,  is  a  Wound.  Only  I 


8  THE    TREATMENT    OF    WOUNDS. 

add  this  restriction,  that  the  Skin  must  be  likewise  divided:  by  which  last 
words  I  exclude  Fractures  that  come  not  through  the  Skin,  and  Contusions 
if  the  exterior  parts  be  continuous.  But  by  the  word  Skin  I  understand 
not  only  the  external  Cutis,  but  also  the  inward  membranes  of  the  Gullet, 
Ventricle,  Guts,  Bladder,  Urethra,  and  Womb  ;  all  which  are  capable  of 
Wounds  from  Sharp  Instruments,  either  swallowed  or  thrust  into  them." 

Though  the  practical  importance  of  the  separate  classification  as  made 
by  this  delightful  old  author,  of  injuries  involving  division  of  the  skin  or 
mucous  membrane  is  still  recognized,  yet  to  make  this  an  important 
element  in  a  general  definition  is  arbitrary  and  artificial. 

The  occurrence  of  a  solution  of  continuity  in  any  of  the  solid  tissues  of 
the  t  body  may  be  due  to  slowly  acting  causes,  as  the  gradual  waste  of 
atrophy  or  the  more  active  disintegration  of  ulceration,  but  a  breach  of 
tissue  thus  affected  would  not  be  a  wound.  There  is  involved  in  the  idea 
the  action  of  a  force  outside  of  the  tissue  itself,  which  by  mechanical 
force  has  rent  or  divided  its  substance.  Even  in  those  cases  in  which 
so-called  spontaneous  rupture  of  muscular  tissue  occurs,  it  is  not  the  con- 
traction of  the  tissues  alone  that  is  the  cause  of  the  rupture,  but  the  force 
opposed  to  it  exerted  through  the  bony  levers  into  which  it  is  inserted. 

The  term  wound,  therefore,  is  susceptible  of  a  very  wide  range  of 
application.  Contusions,  sprains,  fractures,  subcutaneous  as  well  as 
cutaneous  breaches  of  tissue  are  included  in  the  term.  In  all  essential 
particulars  they  will  be  found  to  be  identical  accidents,  involving  the  same 
methods  of  repair  and  subject  to  the  same  principles  of  treatment,  their 
apparent  differences  depending  upon  accidental  differences  of  function, 
nutrition,  relation  to  other  pails,  extent  of  traumatism  suffered,  and  of 
exposure  to  disturbing  influences  from  without 

These  accidental  differences  are  especially  marked  in  the  conditions 
which  those  wounds  of  bones  that  constitute  fractures  present.  Though 
the  method  of  repair,  and  the  principles  involved  in  treatment  are  the 
same  in  these  wounds  as  in  those  of  the  soft  parts,  yet  the  application  of 
these  principles  in  the  varied  fractures  of  the  bones  of  the  skeleton  in- 
volves so  much  of  detail  that,  by  common  consent,  these  wounds  have 
been  classified  apart.  In  accordance  with  this  general  usage,  which  is 
of  practical  importance,  the  consideration  of  fractures  will  be  excluded 
from  the  plan  of  the  present  treatise. 

CLASSIFICATION. — The  first  great  division  of  wounds  is  into  subcutaneous 
and  open  wounds,  the  division  depending  upon  their  relation  to  the 


CLASSIFICATION.  9 

common  covering  of  the  body.  Subcutaneous  wounds  include  all  which 
are  unaccompanied  by  breach  of  the  skin.  Protected  by  the  unbroken  skin 
from  external  irritation  and  infection,  their  repair  is  usually  rapid  and 
undisturbed  by  untoward  complications. 

Open  wounds,  as  a  class,  include  all  which  exhibit  a  breach  of  the 
skin,  or  mucous  membrane.  They  may  present  the  widest  extremes  of 
tissue-breach,  and  of  loss  of  substance.  Those  of  this  class,  whose 
exposed  surfaces  may  be  quickly  brought  and  kept  in  apposition,  differ 
but  little  in  their  gravity  from  subcutaneous  wounds.  Failure  to  secure 
such  apposition,  whether  by  intention  or  from  necessity,  so  modifies 
the  course  and  duration  of  the  process  of  healing,  and  so  exposes  the 
wound  to  dangers  of  disturbance  from  without,  that  such  wounds  con- 
stitute a  well-marked  class  by  themselves.  To  characterize  this  class  only, 
the  term  open  wound  is  most  commonly  employed. 

Wounds  are  again  divided,  from  the  character  of  the  agent  or  force  by 
which  they  are  produced,  into  incised,  punctured,  contused,  lacerated,  gun- 
shot, and  poisoned  wounds,  according  as  the  wounding  agent  has  been  a 
sharp  cutting  edge,  a  penetrating  point,  a  dull  and  bruising  body,  a  tear- 
ing force,  a  projectile,  impelled  by  the  force  of  exploding  gunpowder,  or 
one  which  carries  with  it  into  the  wound  a  poison.  These  divisions,  with 
the  exception  of  the  last,  are  indefinite  general  ones  for  convenience  of  de- 
scription. They  are  all  alike  in  kind,  and  differ  only  in  the  degree  of  the 
injury  sustained.  Whatever  force  or  agent  produces  a  breach  of  tissue, 
occasions  likewise  death  of  tissue  in  the  track  of  the  breach.  The  sharpest 
and  most  delicate  cutting  edge,  when  viewed  through  a  lens  of  sufficient 
magnifying  power,  is  seen  to  be  rough  and  saw-like.  Though  the  extent  of 
the  destructive  action  of  an  instrument  is  lessened  according  to  the  fine- 
ness of  the  edge,  yet  the  track  of  the  keenest  edge  through  a  tissue  is  lined 
by  disorganized  particles  that  have  been  killed  by  its  impact.  Between  a 
slight  and  clean  incised  wound,  in  which  the  destruction  of  tissue  is  limited 
to  the  molecules  traversed  by  the  cutting  instrument,  and  an  extensive 
lacerated  wound  with  roughly  torn  and  contused  edges,  or  between  a  slight 
bruise  and  a  contusion  producing  the  death  and  disorganization  of  large 
masses  of  tissue,  the  difference  is  one  of  degree,  and  not  of  kind.  In  the 
slight  as  well  as  in  the  severe  injury  there  is  dead  tissue  that  must  be 
taken  care  of. 

The  important  practical  difference  which  has  always  been  recognized 
in  the  healing  of  incised  and  punctured  wounds,  as  compared  with  con- 


10  THE    TREATMENT    OF    WOUNDS. 

tused  and  lacerated  wounds,  lias  given  importance  to  these  distinctions  as 
a  basis  for  a  clinical  classification.  These  differences,  however,  depend 
simply  upon  the  difference  in  the  facility  with  which  the  devitalized  tissue 
is  prevented  from  becoming  a  source  of  disturbance  to  the  healing  of  the 
wound  in  the  several  instances. 

The  class  of  poisoned  wounds  embraces  a  much  wider  range  of  injuries 
than  its  traditional  application  was  intended  to  comprehend,  and  the  most 
important  practical  classification  of  wounds  is  based  upon  the  presence  or 
absence  of  poisonous  substances  from  a  wound.  Any  substance  is  a  poi- 
son which,  in  addition  to  the  immediate  gross  chemical  or  mechanical  ef- 
fects which  it  may  produce,  displays  a  specific  subtle  quality  by  which 
the  vitality  of  the  tissues  with  which  it  conies  in  contact  is  degraded,  a 
quality  which  is  shown  by  the  production  of  disturbances  of  the  vital  pro- 
cesses of  an  intensity  out  of  all  proportion  to  the  immediate  injury  that 
may  have  been  inflicted. 

Decomposing  animal  matter,  certain  secretions  of  particular  animals, 
conveyed  by  their  bites  or  stings,  and  certain  vegetable  juices,  when  intro- 
duced into  wounds,  are  followed  by  disturbances  in  their  repair  so  marked 
that  their  separate  classification  as  poisoned  wounds  has  been  natural. 
The  uncomplicated  effects  produced  by  any  traumatisni  have  been  long 
studied  in  subcutaneous  injuries,  in  the  repair  of  which,  even  when  involv- 
ing much  contusion  and  laceration  of  soft  parts  and  extensive  effusion  of 
blood,  as  a  rule,  sloughing,  suppuration,  and  inflammation  do  not  take 
place,  but  the  effused  liquids  and  the  devitalized  tissues  are  removed  by 
absorption  in  due  time,  and  no  disturbance  beyond  that  inflicted  by  the 
original  wounding  agent  is  experienced.  Similar  wounds,  to  which  access 
of  ordinary  atmospheric  air  is  permitted  by  reason  of  a  breach  in  the  skin, 
invariably  have  their  repair  disturbed  by  putrefaction  and  sloughing  of  the 
devitalized  tissues,  by  decomposition  and  liquefaction  of  the  blood-clots, 
by  inflammation  of  the  wound  margins,  and  by  a  prolonged  process  of 
suppuration  and  granulation  in  the  healing  of  the  wound.  Such  results, 
however,  do  not  take  place  when  the  air  which  is  allowed  access  to  a  wound 
is  purified  of  organic  particles  which  are  capable  of  inducing  putrefaction 
in  animal  matter.  Such  wounds,  though  open  and  containing  contused 
and  devitalized  tissues  and  blood-clots,  pursue  the  same  course  of  repair 
as  do  subcutaneous  wounds.  Whenever,  therefore,  inflammatory,  suppura- 
tive,  and  sloughing  conditions  arise  in  an  exposed  wound  it  is  the  result  of 
the  introduction  into  it  of  foreign  matters,  which  act  as  poisons  in  the  dis- 


ASEPTIC    AND    SEPTIC    WOUNDS.  11 

turbances  of  the  reparative  processes  that  they  create.  The  term  poisoned 
wounds  is  thus  made  to  extend  in  its  application  to  the  great  mass  of  open 
wounds,  those  to  which  it  was  originally  applied  being  simply  examples  of 
inoculation  with  special  poisons.  Upon  this  fact  of  the  presence  or  ab- 
sence in  a  wound  of  poisonous  foreign  material  a  classification  of  the 
greatest  practical  importance  is  possible,  viz.,  into  aseptic  and  septic  wounds. 

Aseptic  wounds  include  all  which  are  preserved  from  contamination 
by  poisonous  materials,  whether  such  poison  be  applied  directly  to  it,  or 
be  generated  in  it  by  the  action  of  germs  that  gain  access  to  it  and  find 
within  it  the  conditions  favorable  for  their  growth.  An  aseptic  condition 
in  a  wound  may  be  obtained  either  by  the  protection  which  the  wound 
receives  from  the  first  against  the  access  of  any  septic  agent,  or  by  the 
power  of  living  tissues  to  resist  and  destroy  septic  agents,  or  by  the  appli- 
cation to  the  wound  of  substances  which  destroy  them.  Examples  of  the 
first  class  are  presented  in  subcutaneous  wounds,  and  in  operative  wounds 
which  are  inflicted  with  certain  precautions  ;  examples  of  the  second  class 
are  seen  in  all  open  wounds  in  which  union  by  first  intention  is  secured, 
notwithstanding  at  the  time  of  their  infliction  they  were  freely  exposed  to 
ordinary  air ;  examples  of  the  third  class  are  presented  by  wounds  in 
which  the  application  of  antiseptic  substances  Las  been  successful  in  ar- 
resting the  action  of  whatever  septic  agents  may  have  previously  gained 
access  to  them.  Asepsis  in  a  wound  is  of  the  highest  practical  impor- 
tance. As  long  as  it  is  maintained,  no  decomposition  of  the  secretions  of 
the  wound  takes  place,  no  sloughing  of  killed  or  partly  killed  tissue  oc- 
curs. When  the  proper  cares  to  favor  the  nutrition  of  the  wounded  tis- 
sues are  rendered,  the  healing  of  the  wound  progresses  without  pain, 
inflammation,  or  suppuration,  and  the  least  possible  amount  of  cicatricial 
tissue  is  produced.  To  secure  an  aseptic  condition  in  a  wound,  or  to  ap- 
proach it  as  nearly  as  possible,  is  the  first  and  most  important  indication 
in  wound-treatment. 

Septic  wounds  include  all  in  which  any  agent  capable  of  exciting  fer- 
mentation or  putrefaction  lodges  and  grows.  They  may  present  the  most 
widely  different  degrees  of  wound-disturbances  dependent  upon  the  vary- 
ing conditions  which  the  special  wound  may  present,  and  upon  the  char- 
acter of  the  treatment  which  is  instituted,  but  in  all  cases  they  are 
attended  with  some  degree  of  inflammation  and  suppuration,  and  with 
sloughing  of  dead  tissue.  The  septic  agent  may  be  introduced  by  the 
body  that  inflicts  the  wound,  or  by  the  dressings  that  are  applied,  or  may 


12  THE   TREATMENT    OF    WOUNDS. 

be  among  the  dust  particles  that  float  in  the  air  to  which  it  is  exposed. 
In  very  rare  instances,  also,  it  is  possible  that  it  may  be  conveyed  to  the 
wound  through  the  blood  of  the  wounded  person  himself. 

MODIFYING  INFLUENCES. — The  effects  in  individual  cases  which  particular 
injuries  produce  are  never  the  same,  and  may  widely  differ.  They  are 
modified  by  idiosyncrasy,  mental  state,  age,  previous  constitutional  condition, 
disease,  and  hygienic  conditions. 

Differences  as  to  the  ability  to  bear  injuries  exist  among  races,  nations, 
families,  and  individuals.  The  Latin  races  have  less  resisting  power  than 
the  German  and  Anglo-Saxon.  Oriental  nations  surpass  the  Occidental  in 
their  tolerance  of  injuries.  Of  individuals  of  apparently  equally  good 
physique,  and  enjoying  the  same  hygienic  surroundings  and  treatment, 
one  will  recover  from,  the  most  serious  injury  speedily  and  without  serious 
complication,  while  in  the  other  an  injury,  apparently  much  less  severe, 
may  end  fatally  or  in  prolonged  illness. 

The  power  of  resisting  the  effects  of  extraneous  influences  to  some  de- 
gree is  a  characteristic  of  all  living  matter.  Its  cessation  is  death,  and  a 
dead  tissue  and  a  passive  tissue  are  synonymous.  The  quality  of  the  vital 
resisting  power  inherent  in  the  constitution  of  an  individual  cannot  be 
estimated  by  any  known  signs.  It  may  be  modified  by  other  conditions, 
but  in  some  degree  it  is  always  present  as  a  powerful  unknown  factor 
influencing  the  result  of  any  case.  It  is  a  measure  of  the  vital  force  of  the 
particular  individual,  and  is  what  is  meant  by  the  term  idiosyncrasy  as 
here  used. 

Mental  states  may  modify  greatly  the  effects  of  injuries.  The  shock 
which  attends  the  reception  of  an  injury  is  particularly  closely  associated 
with  mental  conditions.  The  mere  apprehension  of  injury  has  been 
known  to  produce  death  through  shock,  and  the  ability  to  rally  from  the 
physical  impression  made  by  an  injui-y  is  modified  by  the  state  of  mind 
of  the  injured  person.  The  reparative  processes  likewise  are  subject  to 
the  influence  of  mental  conditions.  They  are  promoted  by  the  emotions 
of  hope,  joy,  expectation,  confidence,  and  resignation,  and  may  be  hin- 
dered by  fear,  anxiety,  disappointment,  and  allied  states.  This  is  illus- 
trated on  a  large  scale  by  the  difference  which  has  been  remarked  in  the 
repair  of  wounds  which  have  been  sustained  by  a  -victorious  army  and 
those  by  a  defeated  and  dispirited  one.1  In  general,  it  is  important  to 

"  The  influence  of  the  mental  condition  on  the  results  of  wounds  is  undeniable. 
All  reports  agree  that  the  wounded  of  victorious  troops,  elated  by  the  successes 


INFLUENCE  OF  AGE  ON  REPAIR.  13 

remember  that,  as  it  is  expressed  by  Tuke,1  "The  influence  of  the  mind 
upon  the  body  is  no  transient  power  ;  in  health  it  may  exalt  the  sensory 
functions  or  suspend  them  altogether  ;  excite  the  nervous  system  so  as  to 
cause  the  various  forms  of  convulsive  action  of  the  voluntary  muscles,  01^ 
depress  it  so  as  to  render  them  powerless  ;  may  stimulate  or  paralyze  the 
muscles  of  organic  life,  and  the  processes  of  nutrition  and  secretion — 
causing  even  death  ;  that  in  disease  it  may  restore  the  functions  which  it 
takes  away  in  health,  reinnervating  the  sensory  and  motor  nerves,  exciting 
healthy  vascularity  and  nervous  power,  and  assisting  the  vis  medicatrix 
naturce  to  throw  off  diseased  action  or  absorb  morbid  deposits." 

The  influence  of  age  in  modifying  the  effects  of  wounds  is  exerted  in 
a  threefold  way.  At  the  two  extremes  of  life  the  immediate  shock  from 
injuries  is  more  liable  to  be  serious,  but  in  the  young  it  is  more  quickly 
and  completely  rallied  from,  while  in  the  old  its  development  may  be 
more  slow  in  its  manifestation  and  ultimately  overwhelming  in  its  effects. 
Secondly,  the  reparative  power  is  greater  in  all  parts  of  the  young  than  in 
those  of  the  older  individuals  of  all  species.  The  activity  of  nutrition  in 
youth  favors  repair  after  injury  ;  the  effects  of  this  favorable  influence  are 
notable  in  the  difference  between  the  readiness  and  completeness  of 
repair  in  children  and  that  in  adults.  Lastly,  the  freedom  from  pre- 
existing organic  disease  in  early  life  prevents  complications,  which  be- 
come more  frequent  as  age  advances.  As  the  result  of  these  various  condi- 
tions, the  general  rule  may  be  said  to  be  that,  after  the  age  of  thirty  years, 
the  ability  to  resist  injury  decreases  steadily  with  the  increase  of  years. 

In  connection  with  the  influence  of  age  upon  the  results  of  wounds,  it 
may  be  well  to  recall  the  experience  of  Paget,  as  given  in  a  clinical  lecture 
on  "  The  Various  Eisks  of  Operations.""  He  says:  "We  have  a  large 

achieved  by  their  own  bravery  and  that  of  their  comrades,  did  better  than  those  of 
defeated  armies.  The  most  striking  example  of  this  influence  of  the  mental  con- 
dition in  the  successful  treatment  of  wounds  in  modern  times  is  the  fearful  mortality 
among  the  French,  after  shot  wounds  of  all  kinds,  in  the  war  of  1870-71.  The  ex- 
cessive mortality  of  that  campaign  was  undoubtedly  largely  owing  to  the  mental 
depression  caused  by  a  succession  of  reverses  rarely  met  with  in  the  history  of  war- 
fare "  (Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Part  Third,  Surgical 
Volume,  page  868). 

1  D.  H.  Tuke  :  Influence  of  the  Mind  on  the  Body. 

5  Clinical  Lectures  and  Essays  by  Sir  James  Paget,  Bart.,  edited  by  Howard  Marsh, 
F.R.C.S.  London,  1875. 


14  THE   TREATMENT    OF    WOUNDS. 

number  of  printing  offices  in  the  neighborhood  of  the  hospital ;  and  every 
office  employs  many  boys  from  twelve  to  sixteen  years  old  ;  and  hardly  a 
week  passes  but  we  have  one  or  more  of  these  boys  brought  in  crushed 
by  the  printing-machines.  Fingers,  hands,  and  arms  are  thus  mutilated  ; 
and  I  know  of  no  class  of  patients  that  recover  more  remarkably.  Not 
only  do  they  not  die,  but  their  wounds  heal  steadily  and  quickly  ;  they 
escape  erysipelas  and  spreading  suppurations  and  secondary  haemor- 
rhages ;  and  often,  when,  to  save  any  piece  of  a  hand,  we  leave  bits  of 
skin  that  seem  as  if  they  could  not  live,  they  yet  do  live  and  grow  good 
scars."  Again,  referring  to  those  advanced  in  life,  he  continues:  "All 
the  risks  of  doing  badly  are  at  their  maximum  in  some  among  the  old  ; 
but  these  are  some  of  the  risks  for  wliich  they  will  always  need  your 
especial  care.  The  old  are,  much  more  than  others,  liable  to  die  of  shock, 
or  of  mere  exhaustion  within  a  few  days  after  the  operation.  They  bear 
badly  large  losses  of  blood,  long  exposure  to  cold,  sudden  lowering  of 
temperature,  loss  of  food.  Large  wounds  heal  in  them  lazily  ;  and  hence 
a  prolonged  liability  to  secondary  haemorrhage  and  other  mischiefs  of  open 
wounds.  Their  convalescence  is  often  prolonged  ;  and  you  may  expect  to 
meet  sometimes  with  great  disappointment  in  having  your  old  patients 
die  with  some  slight  casual  disease,  as  if  exhausted  by  the  long  expense 
of  vital  power  in  healing  large  wounds.  They  get  all  but  well :  and 
then,  after  seeming  for  some  time  stationary,  they  fade  and  waste  and 
die." 

Under  the  head  of  "  Constitutional  Conditions,"  are  to  be  classed  cer- 
tain general  states  of  the  blood,  or  of  the  nerves,  or  of  the  general  nutri- 
tion, in  which,  while  there  is  not  a  recognizable  disease,  there  is  still  a 
departure  from  a  perfect  standard  of  health.  It  is  rare,  if  ever,  that  any 
individual  would  satisfy  the  strict  requirements  of  a  perfect  standard,  and 
the  varying  degree  and  combinations  of  departures  from  this  standard, 
which  different  individuals  present,  mark  the  constitutional  differences  of 
individuals.  It  differs  from  what  I  have  termed  idiosyncrasy,  in  that  it  is 
a  measure  of  the  extent  to  which  vitality  has  been  sapped  in  the  tissues 
of  an  individual,  while  the  former  refers  to  the  vigor  with  which  the 
tissues  are  able  to  resist  deteriorating  influences.  Plethora,  anaemia, 
obesity,  these  are  gross  examples  of  constitutional  differences.  I  am 
inclined  to  class  here  also  the  peculiar  vulnerability  of  tissue  which  con- 
stitutes the  scrofulous  diathesis.  The  conditions  which  result  from  ad- 
diction to  alcoholic  stimulants  and  to  gluttony  ;  from  the  exhaustion  of 


INFLUENCE    OF   DISEASE HYGIENIC    CONDITIONS.  15 

overwork,  underfeeding,  or  mental  strain  ;  from  vicious  habits,  and  from 
habitual  inhalation  of  vitiated  air  ;  these  are  some  of  the  more  marked 
examples  of  influences,  which,  by  their  effect  upon  bodily  nutrition  in 
general,  aggravate  the  effects  of  injuries  by  prolonging  the  period  of  their 
repair,  and  rendering  them  more  easily  affected  by  extraneous  disturbing 
influences. 

Closely  allied  to  the  conditions  just  remarked  upon,  are  well-marked 
diseased  states,  such  as  syphilis,  tuberculosis,  malaria,  diabetes  mellitus, 
and  scurvy,  which,  by  the  nutritive  defects  which  they  determine,  delay 
repair,  often  arrest  it,  and  subject  wounds  to  the  most  serious  complica- 
tions. The  pre-existence  of  pyaemia,  septicaemia,  erysipelas,  phlebitis,  or 
any  diffuse  inflammation,  will  add  special  dangers  to  any  superadded 
traumatism.  Diseases  of  the  various  organs  of  the  body,  and  particularly 
cardiac,  pulmonary,  hepatic,  and  renal  diseases,  modify  the  effects  of 
wounds  both  directly,  by  the  constitutional  states  which  they  create  that 
interfere  with  repair  and  diminish  the  resisting  power  of  the  tissues  in 
general,  and  indirectly,  by  the  reaction  of  the  injury  upon  the  pre-existing 
affection,  producing  in  it  temporary  exacerbation,  or  permanent  and 
progressive  aggravation,  with  not  infrequently  speedy  death. 

By  their  relation  to  the  functions  of  nutrition  in  general,  hygienic 
conditions  also  exert  an  important  modifying  influence  on  the  healing 
of  wounds.  Food,  insufficient  in  quantity  or  bad  in  quality,  extremes 
of  temperature,  absence  of  sunlight,  depressing  climatic  conditions, 
lack  of  exercise,  insufficient  and  impure  air — these  not  only  create  pre- 
vious constitutional  conditions  unfavorable  to  repair,  but,  when  continued 
after  the  reception  of  a  wound,  directly  diminish  its  activity.  Erichsen,1 
in  discussing  diet  after  operations,  remarks  :  "  The  soldier  or  the  sailor 
on  active  service  is  often  exposed  to  serious  injuries  that  necessitate  the 
more  important  operations  at  a  time  when  his  constitutional  powers  have 
already  been  broken  down  by  scurvy,  dysentery,  or  some  other  similar 
affection,  resulting  as  much  from  the  deficient  quantity  as  from  the  un- 
wholesome character  of  the  food  with  which  alone  he  can  be  supplied. 
And  after  the  operation  his  only  available  nutriment  may  be  of  the 
coarsest  character,  possibly  salted,  and  imperfectly  cooked.  In  such 
circumstances  operation-wounds  do  not  heal,  or  they  assume  a  peculiar 
gangrenous  character  ;  or  the  patient  sinks  from  ulceration  of  the  intestinal 


Science  and  Art  of  Surgery,  voL  i.,  p.  31.     Philadelphia,  1878. 


16  THE   TREATMENT   OF    WOUNDS. 

mucous  membrane.  The  mortality  of  operations  becomes  enormously 
increased  ;  and  there  can  be  little  doubt  that  thousands  of  deaths  which 
have  occurred  in  wars  between  the  most  civilized  nations  and  the  best 
appointed  armies  may  be  attributed  to  these  causes."  The  important 
influence  which  diet  may  exert  upon  repair  should  not  be  overlooked  in 
the  treatment  of  wounds.  An  ample  supply  of  food,  in  a  digestible  form, 
with  care  observed  that  the  digestive  powers  of  the  patient  should  not  be 
overtaxed,  with  due  regard  to  the  personal  tastes  and  instincts  of  the 
patient,  will  form  the  general  rule  to  be  followed.  The  weather,  in  which 
are  included  temperature,  humidity,  atmospheric  pressure  and  movement, 
may  also  depress  or  stimulate  the  general  nutrition,  and  thus  influence 
the  repair  of  wounds.  Moderately  warm  weather,  if  it  be  not  sultry  and 
oppressive,  favors  repair  tlii-ectly,  and  also  indirectly,  by  encouraging  the 
opening  of  doors  and  windows  and  thus  permitting  free  air-supply.  A 
dry,  clear  atmosphere  is  exhilarating  ;  a  damp,  raw  one,  depressing.  Dr. 
Addinell  Hewson,1  from  a  comparison  of  the  meteorological  records  and 
the  records  of  operations  performed  in  the  Pennsylvania  Hospital  during 
a  period  of  thirty  years,  found  that  with  an  ascending  barometer,  the 
mortality  of  operations  was  a  little  less  than  eleven  per  cent.,  with  a  sta- 
tionary barometer,  more  than  twenty  per  cent.,  and  with  a  descending 
barometer,  more  than  twenty-eight  per  cent.  The  frequency  and  mor- 
tality of  pyaemia  bore  a  direct  relation  to  low  barometrical  pressure  and 
moisture  of  air,  while  the  deaths  from  shock  occurred  in  a  constant  ratio 
with  the  opposite  condition,  dry-ness  of  weather. 

Wales,  in  his  work  on  "  Surgical  Operations  and  Appliances  "  (p.  124), 
speaking  of  the  observations  of  surgeons  in  hot  climates,  that  wounds  heal 
more  quickly  under  an  elevated  temperature  than  the  reverse,  says  : 
"  This  is  strikingly  illustrated  in  the  influence  of  our  high  summer  heats 
over  the  adhesive  process,  which  takes  place  much  more  surely  than  in 
cold  weather  and  damp  cool  latitudes.  The  same  thing  is  observed  in 
the  constitution  of  the  Arab,  whose  climate,  active  habits,  and  diet  pro- 
duce a  spare  and  sinewy  frame  and  a  sort  of  dry  temperament  very 
favorable  for  the  quick  healing  of  wounds.  I  have  made  the  same  ob- 
servation in  some  parts  of  the  East  Indies,  where  the  population  is  under 
analogous  influences.  In  the  Gulf  of  Mexico  the  heat  during  the  summer 
is  excessive  ;  and  it  was  during  a  period  of  this  sort  of  weather  that  I 

1  Pennsylvania  Hospital  Reports,  1869. 


INFLUENCE    OF    CLIMATE SUNLIGHT.  17 

received  into  the  hospital  under  my  charge,  at  the  mouth  of  the  Missis- 
sippi River,  a  large  number  of  the  wounded  during  the  naval  operations 
against  New  Orleans.  Though  the  buildings  were  crowded  with  the 
wounded  and  fever  patients,  all  of  the  wounds  healed  with  unusual  ra- 
pidity ;  and  of  fifteen  cases  of  amputation  of  the  thigh  and  arm,  but  two 
died,  both  of  them  after  secondary  operations,  one  of  the  patients  having 
lost  a  good  deal  of  blood  from  having  his  knee  shattered  by  a  rifle-shot ; 
in  the  other  case,  disarticulation  was  performed  at  the  shoulder  for  a  gun- 
shot wound  of  both  the  axillary  artery  and  vein.''  Rochard,  in  speaking 
of  the  healing  of  wounds  in  hot  climates,  says  :  "  All  of  our  confreres 
point  out  the  rapidity  of  their  course  and  the  promptitude  Avith  which 
they  heal.  I  have  myself  been  able  to  verify  it  often  in  Madagascar.  The 
bad  guns  of  which  the  Sacolares  made  use,  often  burst  in  their  hands,  and 
I  have  seen  some  of  these  complicated  wounds,  for  which  I  had  proposed 
amputation,  heal  with  a  wonderful  facility,  in  spite  of  the  most  irrational 
treatment.  Intertropical  climates  are  favorable  to  the  efforts  of  conserva- 
tive surgery ;  and  operations,  when  it  is  impossible  to  avoid  them,  suc- 
ceed better  there  than  in  Europe.  The  same  observation  has  been  made 
in  Oceanica,  on  the  coast  of  Africa,  in  South  America,  and  in  the  Antilles. 
It  explains  the  almost  constant  success  of  the  amputations  of  naval  sur- 
geons in  equatorial  stations,  and  the  remarkable  cures  that  they  often 
obtain  when  it  is  possible  to  abstain  from  them." 

The  stimulating  effects  of  sunlight  upon  nutrition  should  also  be  re- 
garded in  the  hygienic  management  of  the  wounded.  Next  to  the  neces- 
sity of  fresh  air  supply,  that  of  sunlight  has  assumed  importance  in  the 
present  prevailing  views  as  to  the  arrangement  of  hospital  wards.  There 
is  an  instinctive  craving  for  the  light  innate  in  all  living  beings,  which 
becomes  more  marked  whenever,  for  any  reason,  there  is  a  depression  of 
vital  power.  Both  pathetic  and  truthful  is  the  observation  of  Florence 
Nightingale,  in  her  "Notes  on  Nursing,"  that  ';it  is  curious  to  observe 
how  almost  all  patients  lie  with  their  faces  turned  to  the  light,  exactly 
as  plants  make  their  way  toward  the  light.  A  patient  will  complain  that 
it  gives  him  pain  lying  on  that  side.  'Then  why  Jo  you  lie  on  that 
side?'  He  does  not  know,  but  we  do.  It  is  because  it  is  the  side 
toward  the  window."  The  effects  of  sunlight  upon  nutrition  and  growth 
have  an  excellent  illustration  in  the  hygiene  of  the  growing  child.  The 
special  application  of  this  illustration  to  the  course  of  wounds  in  adults 
depends  upon  the  fact  that  in  the  repair  of  all  wounds  there  is  a  return  of 


18  THE   TREATMENT    OF    WOUNDS. 

the  local  tissues  engaged  in  the  repair  to  that  condition  which  marks  the 
tissues  in  general  of  the  growing  child. 

Insufficient  air  is  synonymous  with  impure  air,  for  the  purest  air,  if 
not  renewed  with  sufficient  frequency  becomes  speedily  poisoned  by  the 
exhalations  from  the  persons  of  those  breathing  it.  This,  which  is  true  in 
health,  is  still  more  quickly  accomplished  when  the  bodily  exhalations  are 
rendered  more  offensive  by  disease.  It  becomes  therefore  more  important 
for  the  well-doing  of  the  sick  than  it  is  for  the  welfare  of  the  well  that  an 
unlimited  supply  of  pure  air  should  be  supplied.  When  to  the  natural 
sources  of  air-contamination  there  is  added  the  emanations  of  suppurating 
wounds  the  need  of  constant  change  in  the  surrounding  air  is  more  em- 
phatic still,  if  its  purity  is  to  be  preserved.  While  much  attention  has 
been  directed  to  the  importance  of  the  adequate  ventilation  of  hospitals,  in 
the  wards  of  which  numbers  of  wounds  are  assembled,  it  should  not  be  for- 
gotten that  the  same  necessity  exists  for  isolated  cases  in  their  own  homes 
that  they  do  not  become  sources  of  infection  to  themselves.  Absolutely 
pure  air  is  not  attainable  in  the  ordinary  conditions  of  life.  While  it  is 
the  great  oxygen-carrier  for  the  needs  of  the  living  body,  it  receives  in  ex- 
change from  the  body  the  debris  of  its  disintegration.  It  is  the  vehicle  of 
transportation  of  an  infinite  variety  of  floating  matter,  the  great  mass  of 
which  is  organic  in  character.  Putrescible  organic  matter  cannot  long  be 
exposed  to  the  air  without  becoming  the  recipient  of  putrefactive  germs 
from  it.  Aseptic  wounded  surfaces  quickly  become  septic  when  exposed 
to  it  by  reason  of  the  floating  septic  particles  that  it  conveys.  The  best 
stimulant  to  the  vital  resisting  power  of  a  living  tissue,  by  which  the  effects 
of  sepsis  is  antagonized  and  overcome  is  perfectly  oxygenized  blood.  The 
air  thus  carries  both  the  bane  and  the  antidote.  The  practical  end  there- 
fore to  be  aimed  at,  in  any  given  air-supply,  is  that  there  shall  be  as  small 
a  proportion  of  the  bane  and  as  large  a  proportion  of  the  antidote  as  pos- 
sible. This  involves  the  removal,  the  suppression,  or  the  diffusion,  as  much 
as  possible,  of  all  sources  of  contamination,  and  the  dilution  of  that  which 
is  unavoidable  by  the  introduction  of  the  largest  quantity  practicable  of 
the  purest  air  attainable.  The  purity  and  the  sufficiency  of  the  air  are 
thus  seen  to  have  a  double  relation  to  the  healing  of  wounds,  one  a  general 
relation,  which  the  air  shares  with  other  hygienic  conditions,  and  the  other 
a  special  relation  as  a  carrier  of  and  an  antidote  to  sepsis.  This  latter  re- 
lation demands  further  notice.  As  the  sources  of  infection  are  multiplied 
nnd  brought  near  to  wounds  capable  of  becoming  infected,  will  the  action 


CHARACTER    OF    A1K.       SUPPLY.  19 

of  the  air  as  a  medium  of  infection  be  exemplified  in  its  highest  degree. 
This  is  accomplished  by  the  accumulation  of  numbers  of  septic  wounds  in 
one  building  with  limited  ventilation  capacity.  Says  Erichsen,1  "The 
overcrowding  of  wounded  people,  whether  the  wounds  be  accidental  or 
surgical,  will  inevitably  produce  one  of  the  four  septic  diseases,  pha- 
gedrena,  septicaemia,  py;ernia,  or  erysipelas.  When  the  word  '  overcrowd- 
ing' is  used  in  connection  with  surgical  hygiene,  it  does  not  mean  the 
heaping  together  of  the  sick  and  wounded  in  one  building  beyond  what  it 
is  intended  to  hold ;  but  it  means  the  accumulation  in  one  ward  or  under 
one  roof  of  a  greater  number  of  patients  than  is  compatible  with  such 
purity  of  air  as  to  render  the  septic  poison  incapable  of  development  or  of 
propagation  in  it." 

The  value  of  air  as  an  antiseptic  agent  is  shown  by  the  diminished  pre- 
valence of  septic  diseases  when  those,  who  by  reason  of  open  wounds  are 
favorable  subjects  for  their  development,  are  isolated  from  each  other,  and 
are  supplied  with  abundance  of  comparatively  pure  air.  Still  the  air,  how- 
ever great  its  quantity,  does  not  destroy  the  particles  of  infection  that  it 
dilutes.  It  acts  only  by  increasing  the  resisting  power  of  the  tissues  and 
by  lessening  the  amount  of  the  infective  material  deposited  at  any  one 
time.  It  is  the  presence  of  these  infective  particles  that  make  it  important 
that  to  a  person  suffering  from  an  open  wound  an  amount  of  air  should  be 
supplied  in  excess  of  that  required  for  the  ordinary  purposes  of  healthy 
life.  "Whatever  means  then  may  diminish  the  number  or  activity  of  the 
agents  of  infection  will  by  that  much  reduce  the  importance  of  an  unusual 
air-supply  in  the  treatment  of  wounds. 

In  concluding  these  paragraphs  on  the  general  modifying  conditions 
that  influence  the  course  of  wounds,  I  remark  that  their  pertinency 
depends  upon  the  truth  that  the  treatment  of  a  wound  involves  the  treat- 
ment not  only  of  the  particular  breach  of  continuity,  but  also  of  the 
wounded  person  as  a  whole.  It  is  possible  that  in  the  special  direction  of 
attention  to  the  details  of  local  treatment,  matters  concerning  the  general 
state  of  the  patient  may  be  overlooked  or  slighted.  Too  often,  perhaps, 
this  is  the  case.  The  duty  of  the  surgeon  extends,  however,  beyond  the 
restricted  field  of  binding  up  the  wound  and  keeping  it  free  from  irrita- 
tion. His  ministry  to  the  mental  state  of  the  wounded  may  be  of  the 
utmost  importance.  The  ability  to  excite  in  the  minds  of  those  subject  to 


•  Science  and  Art  of  Surgery,  vol.  i.,  p.  33.    Philadelphia,  1878. 


20  THE    TREATMENT    OF    WOUNDS. 

his  care  a  feeling  akin  to  that  of  the  beleaguered  garrison  of  Metz  toward 
Pare,  who  cried  out  upon  his  arrival  among  them,  "  We  have  no  longer 
any  fear  of  dying,  even  if  we  should  be  wounded ;  Pare,  our  friend,  is 
among  us,"  may  make  the  difference  between  life  and  death.  The  special 
risks  from  age,  from  the  previous  constitutional  condition,  or  diseases  of 
the  injured,  must  be  appreciated  and  met,  and  the  hygienic  conditions  in 
which  the  wounded  man  is  placed  must  be  made  as  good  as  possible, 
before  the  whole  duty  of  a  surgeon  is  accomplished. 


CHAPTER  II. 

THE  IMMEDIATE  EFFECTS  OF  WOUNDS  IX  GENERAL— THE    RE- 
PAIR OF  WOUNDS— INFLAMMATION. 

Constitutional  Effects— Shock— Reaction— Traumatic  Fever— Load  Effects— Impair- 
ment of  Function— Gaping — Pain— Hemorrhage— Active  Hyperaemia —  Union  »f 
Wound*— Exudation—  Vascularization — Connective- tissue  Transformation — Cica- 
trization—Union by  First  Intention— Causes  of  Modified  Repair— Defects  of  Appo- 
sition— Defects  of  Protection — Defects  of  Nutrition — Modified  Normal  Repair 

Healing  by  Granulation— Healing  by  Secondary  Adhesion—  Healing  by  Scabbing — 
Suppuration — Disposition  of  Effused  Blood  and  Dead  Tissue — Destructive  Dis- 
turbances of  Repair — Inflammation — Infectious  Wound-Diseases. 

THE  immediate  effects  of  a  wound  are  twofold  in  character,  constitutional 
and  local. 

CONSTITUTIONAL  EFFECTS. — All  wounds,  of  every  degree,  produce  at  first 
a  depressing  effect  upon  the  whole  body.  This  is  accomplished  through 
the  nervous  system,  may  "be  so  slight  and  transitory  as  to  be  unnoticed, 
or  may  be  so  profound  as  to  cause  instant  death.  This  general  depression 
constitutes  shock.  It  manifests  itself  most  prominently  through  the 
circulation  by  diminution  in  the  contractile  force  of  the  heart  and 
arteries — reflex  vaso-motor  paralysis.  The  varying  degrees  of  depression 
of  nerve-force  and  of  heart-failure  which  may  be  produced  by  the  inflic- 
tion of  a  wound  cause  the  symptoms  of  shock  to  vary  from  momentary 
pallor  and  mental  confusion  to  a  condition  of  profound  prostration. 
When  the  vital  powers  rally  from  this  state  of  depression  and  the  differ- 
ent organs  begin  to  resume  their  proper  functions  reaction  is  said  to  have 
taken  place.  In  the  most  favorable  cases  reaction  is  gradual  and  pro- 
gressive, though  it  may  occupy  many  hours,  or  even  days,  in  its  course. 
Returning  color  to  the  face  and  increased  power  in  the  heart's  action  are 
its  earliest  signs.  In  certain  cases  fluctuations  in  the  reaction  occur, 
relapse  alternating  with  improvement  for  a  variable  time.  In  some  cases 
there  is  an  imperfect  reaction,  characterized  by  rapid  and  weak  heart's 


22  THE   TREATMENT    OF    WOUNDS. 

action,  cerebral  excitement,  muscular  tremor,  and  high  body  temperature. 
The  result  of  such  a  condition  is  doubtful,  speedy  death  or  ultimate 
recovery  after  a  prolonged  struggle  being  possible. 

The  reaction  from  shock  is  commonly  attended  with  elevation  of  the 
body  temperature,  quickening  of  the  pulse,  thirst,  derangement  of  the 
secretions,  restlessness,  and  headache.  This  fever  of  reaction  may  be  so 
trifling  and  evanescent  as  to  escape  notice  ;  its  grade  of  severity  depends 
chiefly  upon  the  nervous  excitability  of  the  patient,  his  previous  constitu- 
tional condition,  and  the  amount  of  local  irritation  produced  by  the  injury. 
Children  manifest  it  most  readily.  It  is  of  reflex  nervous  origin,  makes 
its  appearance  usually  -within  a  few  hours  after  the  reception  of  an  injury, 
and  may  be  expected  to  decline  on  or  after  the  second  day.  Its  most 
severe  manifestations  are  seen  in  cases  of  imperfect  reaction,  its  combina- 
tion with  which  produces  the  condition  of  excitement  with  prostration 
which  characterizes  these  cases.  It  may  be  dangerously  intense,  and  is 
then  apt  to  be  accompanied  by  a  delirium,  which  is  generally  wild  in 
character  but  temporary  in  duration,  subsiding  with  the  restoration  of 
the  general  bodily  functions.  This  reactive  fever  is  to  be  distinguished 
from  the  fever  which  complicates  the  repair  of  injuries,  which  does  not 
develop  until  two  or  three  days  after  an  injury,  and  is  dependent  upon 
general  blood-infection  by  absorption  of  septic  matters  from  the  injured 
part.  The  two  might  very  properly  be  designated  as  primary  and  second- 
ary traumatic  fever.  The  secondary  is  often  engrafted  upon  the  primary. 

LOCAL  EFFECTS. — All  breaches  of  tissue  are  produced  either  by  a  force 
of  traction,  tearing  asunder  the  elements  from  each  other,  or  by  direct 
pressure  forcing  the  elements  asunder.  The  first  constitutes  a  laceration? 
the  second  a  contusion.  When  a  laceration  is  inflicted  a  greater  amount 
of  damage  is  likely  to  have  been  done  than  the  particular  breach  would 
indicate,  owing  to  the  wide  distribution  of  the  effects  of  the  strain,  the 
culmination  of  which  at  the  point  of  rupture  alone  is  declared  by  the 
wound.  The  strains,  rents,  and  ruptures  of  ligaments  and  capsules  that 
result  from  joint- wrenches,  distortions,  or  dislocations,  muscular  ruptures, 
the  sprains  of  tendons  and  tendon-sheaths  occasioned  often  in  violent 
manual  efforts,  the  tearing  away  of  epiphyses  and  bony  prominences 
through  strain  upon  the  muscles  or  ligaments  attached  to  them,  and  rents 
in  the  substance  of  internal  organs,  or  their  separation  from  their  con- 
nections by  the  jar  of  falls,  are  examples  of  subcutaneous  lacerations.  By 
the  prolonged  impairment  of  function  which  they  produce  they  illustrate 


LOCAL    EFFECTS    OF    WOUNDS.  23 

the  force  of  the  statement  as  to  the  wide  distribution  of  the  effects  of 
strain.  A  contusing  force  may  likewise  act  as  a  lacerating  force  upon  the 
tissues  beyond  the  range  of  its  direct  impact,  and  the  most  severe  wounds, 
as  regards  the  difficulties  which  attend  their  treatment,  are  those  in  which 
laceration  and  contusion  are  combined,  as  in  the  accidents  produced  from 
the  entanglement  of  limbs  in  machinery  or  by  their  crushing  under  the 
wheels  of  cars.  In  a  pure  contusion,  however,  that  is  a  breach  produced 
by  direct  pressure  only,  the  traumatism  is  limited  in  its  extent  by  the 
area  of  the  impact,  but  the  crushing  of  the  tissues  may  be  of  any  grade, 
from  the  imperceptible  molecular  divisions  of  a  clean  incision  or  a  slight 
bruise  to  the  purification  of  large  masses  of  tissue. 

The  local  effects  of  a  wound,  however  produced,  may  be  classified  under 
the  five  divisions  of,  1,  Impairment  of  Function  ;  2,  Gaping  ;  3,  Pain  ;  4, 
Haemorrhage  ;  5,  Active  Hypercemia.  Of  these,  the  four  first  can  receive 
here  but  the  briefest  mention.  The  last  will  exact  more  consideration,  as 
it  is  the  initial  condition  upon  which  is  built  up  the  consequent  repair 
of  the  wound. 

Impairment  of  function  is  the  necessary  and  immediate  result  of  tissue- 
breach.  Its  character  is  determined,  in  a  particular  wound,  by  the  vary- 
ing functions  and  relations  of  the  tissues  that  have  been  severed.  Its 
extent  and  duration  will  depend  upon  the  amount  of  injury,  the  activity 
and  regularity  of  the  processes  of  repair,  the  perfection  of  repair  of  which 
the  tissue  is  susceptible,  and  the  amount  of  new  material  needed  to  fill 
up  any  gap  between  the  divided  tissues  that  may  have  resulted  from  loss 
of  substance  or  gaping. 

Gaping  depends  upon  the  contractility  of  the  tissues  and  is  due  to  the 
destruction,  by  the  solution  of  continuity  of  the  tissue,  of  the  natural  force 
by  which  they  are  kept  extended.  It  becomes  important  when  the  wound 
is  transverse  to  the  direction  of  the  principal  fibres  of  an  organ.  Tissues 
in  a  state  of  tension,  tissues  in  whose  structure  there  is  much  elastic  tis- 
sue, as  the  skin  and  arteries,  and  tissue  that  lias  the  power  of  contract- 
ing, as  muscular  tissue,  when  wounded,  exhibit  gaping  in  the  most 
marked  degree. 

Pain  results  from  the  impression  made  upon  the  sensory  nerves  of  the 
part,  and  hence  varies  with  the  nerve-supply  of  the  parts.  The  tempera- 
ment, likewise,  of  the  individual,  modifies  the  amount  of  pain  experienced. 
Mental  preoccupation  or  excitement  often  prevents  the  perception  of  pain. 
Great  rapidity  in  the  infliction  of  a  wound  diminishes  the  pain  resulting. 


24  THE    TREATMENT    OF    WOUNDS. 

Extensive  operations  with  the  assistance  of  the  "  surgical  engine,"  by 
which  the  instruments  used  are  made  to  revolve  with  inconceivable  rapid- 
ity, may  be  done  with  little  or  no  pain.  A  temporary  benumbing  of  the 
parts  is  produced  when  the  injury  is  instantaneously  inflicted.  Subsequent 
sensation  is  one  of  smarting  or  burning.  This  is  experienced  in  all  wounds, 
and  is  of  short  duration. 

The  amount  of  haemorrhage  which  is  provoked  by  a  wound  depends 
upon  the  number,  size,  and  character  of  the  wounded  vessels,  and  the  con- 
ditions which  either  the  situation  of  the  wound  itself  or  the  art  of  the 
surgeon  supplies  to  arrest  it.  The  natural  haemostatic  is  the  coagula- 
tion of  the  blood,  which  spontaneously  seals  up  the  divided  exti-emities  of 
the  capillaries  and  smaller  vessels,  filling  them  as  far  as  to  the  next 
branches  of  the  vascular  network.  In  open  wounds  the  effused  blood,  in 
great  part,  either  spontaneously  flows  away  or  may  be  wiped  away  ;  a 
slight  layer  of  coagulated  blood,  however,  remains,  with  rare  exceptions, 
in  the  interstices  of  the  wound  surfaces.  In  subcutaneous  wounds  the 
character  of  the  tissue  in  which  the  vessels  lie  influences  also  the  extent 
of  blood-effusion.  Loose  connective  tissue  favors  extensive  and  rapid  infil- 
tration. The  escape  of  blood  into  the  cavities  of  the  body  may  be  a  dan- 
gerous complication  both  by  reason  of  the  possible  amount  of  the  haemor- 
rhage, and  from  the  pressure  which  it  may  exert  upon  important  organs. 
Blood-clot  may  interfere  with  repair,  either  mechanically,  by  preventing 
apposition  of  the  wound-surfaces  and  maintaining  a  gap  to  be  slowly  filled 
up  by  new  tissue,  or  by  affording  a  favorable  substance  for  the  lodgement 
and  development  of  septic  matter  from  without. 

The  parts  immediately  adjacent  to  a  wound  speedily  swell  somewhat, 
and  by  their  increased  redness  show  some  capillary  turgescence.  From 
the  dilated  capillaries  an  amount  of  plasma  is  exuded  in  excess  of  the  nor- 
mal, which  infiltrates  the  tissues  adjacent  to  the  wound  and  appears  as  a 
more  or  less  copious  effusion — wound-secretion — upon  the  free  surface  of 
the  wound  when  accurate  apposition  is  not  maintained.  The  amount  of 
this  capillary  dilatation  and  of  the  consequent  effusion  and  swelling,  can 
be  greatly  restricted  by  shielding  the  wound  from  further  irritation,  keep- 
ing the  parts  at  perfect  rest,  and  subjecting  them  to  equable  and  gentle 
compression.  A  certain  amount  of  capillary  distention  in  the  wound- 
flaps  may  be  passive,  the  result  of  the  closure  of  a  part  of  the  blood-paths, 
by  which  a  less  numerous  series  of  channels  are  provided  for  the  trans- 
mission of  the  same  amount  of  blood,  but  the  chief  element  in  its  produc- 


ACTIVE    HYPEU.EMIA.  25 

tion  has  been  demonstrated  to  be  a  quality  inherent  in  the  capillary  ves- 
sels of  dilating  when  irritated.  The  first  and  immediate  effect  of  the  irri- 
tation of  any  part  is  increased  activity  of  the  capillary  circulation  of  the 
affected  part.  The  capillaries  dilate  and  the  blood-pressure  in  them  in- 
creases. This  state  is  called  active  hypero^mia,  or  afflux,  and  occurs  only 
as  the  result  of  irritation,  and  in  wounds  is  the  direct  consequence  of 
the  local  irritation  produced  by  the  traumatism  that  has  at  the  same  time 
produced  the  solution  of  continuity.  In  addition  to  this  quality  of  dilata- 
tion displayed  by  the  vessels  themselves,  it  is  probable  that  in  most  inju- 
ries there  is  present  the  added  influence  of  the  vaso-dilator  nerves,  affected 
indirectly  through  the  sensory  nerves  of  the  implicated  1'egion,  for  it  has 
been  observed  that  excitation  of  a  sensory  nerve  produces  increased 
activity  of  the  capillary  circulation  in  the  part  in  which  the  nerve  origi- 
nates. This  active"  hypeneniia  quickly  subsides,  without  having  produced 
any  marked  alteration  in  normal  tissues,  when  the  irritation  ceases,  if 
it  has  been  temporary.  But  when  the  irritating  force  has  at  the  same 
time  produced  a  breach  of  tissue,  the  hypersemia  is  prolonged  and 
quickly  provokes  active  tissue -changes.  These  changes  consist  of  ex- 
udation and  cell-germination.  Through  the  conditions  which  these  new 
processes  introduce  into  the  wound,  agglutination  and  ultimate  firm 
union  of  the  divided  tissues  by  a  more  or  less  highly  organized  bond  is 
effected. 

UNION  OP  WOUNDS. — The  preceding  description  of  the  capillary  condi- 
tions that  produce  arid  characterize  the  active  hypersemia  that  follows 
wounds  has  been  based  upon  the  observations  of  Strieker.1  The  suc- 
ceeding statements  as  to  the  character  of  the  histological  changes  that 
attend  the  process  of  repair  are  derived  from  the  same  authority.  The 
immediate  effects  of  a  wound  have  been  traced  to  the  point  where  an 
exudation  -of  liquid  from  the  hypersemic  capillaries  has  taken  place.  This 
exudation  consists  of  an  increased  effusion  from  the  vessels  of  nutritive 
plasma,  or  coagulable  lymph,  with  some  of  the  white  corpuscles  of  the 
blood.  The  exuded  plasma  is  appropriated  by  the  cellular  elements  of 
the  tissues.  Under  its  stimulus,  these  normal  tissue-cells,  which  had 
become  contracted  and  fixed,  enlarge,  absorb  the  basis  substance  in 
which  they  are  embedded,  multiply  by  segmentation,  and  again  become 
amoaboid  and  capable  of  development  and  organization  into  new  tissue, 

1  Disturbances  of  Nutrition  and  Pathology  of  Inflammation.  The  International 
Encyclopaedia  of  Surgery,  vol.  i.  New  York :  William  Wood  &  Co.,  1882. 


26  THE    TREATMENT    OF    WOUNDS. 

being  identical  in  character  with  embryonic  tissue,  the  characteristic  of 
which  is  that  it  is  composed  of  amoeboid  cells,  separated  by  narrow  traces 
of  intermediate  or  basis  substance,  and  that  these  cells  or  masses  tend  to 
multiply  actively  by  segmentation,  and  by  a  power  of  differentiation 
inherent  in  themselves  produce  the  development  and  growth  of  the 
different  organs  and  tissues  of  the  body.  The  older  the  tissue  becomes, 
the  greater  proportion  does  the  intermediate  substance  acquire,  and  the 
more  slender  are  the  cells  and  their  processes.  It  is  proper  to  say, 
therefore,  that  the  divided  tissues  which  are  in  process  of  reunion  return, 
as  a  preliminary  step,  to  the  embryonic  state.  By  the  proliferation  of  the 
tissue-cells  thus  revivified  new  cells  are  developed,  and  the  process  of 
cell-formation  continues  until  the  breach  is  filled.  TJie  new  material  thus 
formed,  consisting  of  cells  embedded  in  a  slight  amount  of  gelatinous 
uniting  substance,  blends  with  the  softened  reverted  tissue  on  either  side, 
and  forms  a  bond  of  union  that  within  twenty-four  hours  is  sufficiently 
formed  to  agglutinate  the  divided  surfaces.  There  follow  next,  in  due 
order,  the  vascularization  and  the  connective-tissue  transformation  of  this 
new  tissue.  Within  a  few  hours  new  capillary  loops  extend  into  the  cell- 
mass  from  the  surfaces  of  the  recently  divided  tissue.  These  inosculate 
freely  with  each  other.  With  the  restoration  of  the  circulation  through 
the  new  tissue,  the  active  lrypera>inia  in  the  adjacent  blood-vessels  sub- 
sides, and  a  retrograde  metamorphosis  of  the  cell-mass  begins.  Some 
of  the  cells  become  entirely  converted  into  basis,  or  connective  substance, 
while  others  remain,  but  contracted  and  changed  in  form  by  a  similar 
transformation  of  portions  of  their  mass  at  their  circumference,  into  ba- 
sis substance.  The  basis  substance  speedily  becomes  quite  stiff  and  fib- 
rinous,  and  assumes  a  fixed  character  which  is  influenced  by  the  adja- 
cent tissue.  The  fixed  character  finally  assumed  by  this  basis  substance 
determines  the  ultimate  character  of  the  new  tissue.  As  a  rule,  the 
highest  development  which  the  new  material  formed  can  reach  is  that  of 
connective  tissue,  but  a  perfect  regeneration,  as  regards  form  and  function 
in  the  case  of  nerve,  muscle,  and  bone  tissue  may  be  attained.  The 
capillary  network  formed  in  the  new  tissue  is  at  first  more  abundant  than 
that  of  the  adjacent  tissue,  so  that  the  cicatrix  appears  as  a  fine  red  stripe, 
but  in  the  further  history  of  the  tissue  a  tendency  to  condensation  and 
atrophy  is  manifested,  by  which  a  large  proportion  of  the  newly  formed 
vessels  become  converted  into  solid,  fine  connective-tissue  strings,  and  the 
whole  cicatricial  tissue  contracts  and  pales,  becoming  more  dense  and 


PRIMARY    ADHESION.  27 

%of  a  lighter  color  than  the  adjacent  tissue.  The  repair  of  all  breaches  of 
tissue  is  accomplished  by  essentially  the  same  process,  subject  only  to 
minor  differences  arising  from  peculiarities  of  structure.  This  process 
consists — as  has  been  now  described — in  a  modification  simply  of  the 
normal  nutritive  processes  at  the  seat  of  injury,  by  which  the  tissues  to 
be  repaired  return  to  their  embryonic  state,  and  new  embryonic  tissue  is 
formed  between  them  with  which  they  blend.  By  the  organization  and 
development  of  the  new  tissue  a  permanent  bond  of  union  is  formed.  In 
no  case  is  union  of  divided  tissue  effected  without  the  interposition  of 
new  material.  "When  divided  tissues  are  at  once  brought  into  perfect 
apposition,  and  there  retained  and  shielded  from  disturbance,  the  amount 
of  new  tissue  required  for  the  accomplishment  of  union  will  be  extremely 
small,  and  may  be  with  difficulty  recognizable,  but  its  existence  in  suffi- 
cient degree  is  nevertheless  undeniable. 

When  rapid  and  uncomplicated  union  of  divided  surfaces  takes  place, 
union  by  first  intention,  or  by  primary  adhesion,  is  said  to  have  been 
accomplished.  It  is  seen  in  its  ideal  perfection  in  the  repair  of  many 
simple  incised  wounds,  in  which,  even  by  the  third  day,  the  union  may  be- 
come so  firm  that  extraneous  means  of  retention  are  no  longer  necessary. 

To  secure  this  primary  adhesion  it  is  necessary  that  a  close  apposition 
of  the  divided  surfaces  be  effected  and  preserved,  that  all  sources  of  irrita- 
tion be  avoided,  and  that  the  conditions  which  favor  nutrition  in  general 
be  maintained.  When  any  of  these  conditions  fail  to  be  secured,  modifica- 
tions in  the  typical  process  take  place.  The  conditions  that  modify  the 
processes  of  repair,  and  tend  to  prevent  union  by  first  intention  may  be 
classified  as  1,  defects  of  apposition  ;  2,  defects  of  protection ;  3,  defects  of 
nutrition.  An  analysis  of  the  various  conditions  included  in  each  of  these 
classes  is  subjoined.  Each  is  of  importance  in  guiding  the  treatment  to 
be  adopted  in  any  given  case,  and  will  repeatedly  reappear  for  considera- 
tion in  the  succeeding  pages  of  this  work. 

DEFECTS  OF  APPOSITION. — Close  apposition  of  divided  surfaces  may  be 
prevented  by : 

a.  The  natural  gaping  of  the  divided  tissues  in  the  absence  of  the 

necessary  means  of  coaptation  and  retention. 

b.  The  character  of  the  injury-  itself,  as  in  superficial  excoriations  and 

burns,  and  in  wounds  in  which  there  has  been  an  extensive 
loss  of  substance,  or  by  which  a  large,  flat  surface  has  been 
exposed. 


28  THE    TREATMENT    OF   WOUNDS. 

c.  The  accumulation  between  the  divided  surfaces  of  blood  and  of 

wound-secretions. 

d.  The  presence  of  foreign  matter  between  the  wound  surfaces. 
DEFECTS  OF  PROTECTION. — By  failure  to  properly  protect  a  wound  the 

injured  tissues  may  be  exposed  to  continued  or  repeated  irritations.     The 
sources  of  such  irritation  may  be  found  in : 

a.  Motion,  by  which  the  apposition  of  the  divided  surfaces  is  dis- 

turbed, rupture  of  the  new  adhesive  material  produced,  and 
the  conditions  of  the  original  injury  renewed  in  tissues  already 
weakened  by  that  injury. 

b.  Direct  mechanical  violence,  which  includes  not  only  rude  handling, 

friction,  and  gross  mechanical  injuries  of  every  kind,  but  also 
the  less  tangible  injuries  inflicted  by  minute  foreign  particles 
that  may  have  been  permitted  to  remain  in  a  wound. 

c.  Chemical  irritants,  including  the  products  of  the  decomposition  of 

retained  secretions,  and  of  masses  or  particles  of  dead  tissue. 

d.  Infection  by  poisonous  agents,  including  the  floating  organic  mat- 

ter of  the  atmosphere. 

DEFECTS  OF  NUTBITION. — The  causes  of  defective  nutrition  may  be 
general  and  local.  The  general,  or  constitutional  conditions  which  pro- 
duce defective  nutrition  have  already  been  considered  (see  page  14). 
The  local  conditions  are  those  which  affect  the  circulation  and  the  inner- 
vation  of  the  part  to  be  repaired.  The  primary  active  hyperaemia  may  be 
rendered  excessive  and  prolonged,  and  nutrition  be  thus  disturbed,  by  an 
improper  position  of  the  injured  part  or  by  any  impediment  to  the  return 
circulation.  The  prolonged  application  of  cold  impairs  nutrition.  Ten- 
sion in  the  wround  acts  by  obstructing  the  flow  of  the  blood  in  the 
capillaries,  and  thus  disturbing  cell  development  and  formation,  a  defect 
in  nutrition. 

The  modifications  which  these  various  conditions,  separately  or  in 
combination,  may  determine,  may  be  divided  according  as  the  disturb- 
ances which  they  provoke  result  simply  in  prolongation  of  the  healing 
and  waste  of  the  reparative  material,  or  in  arrest  of  nutrition  and  necrosis 
of  tissue.  The  former  may  still  be  considered  as  examples  of  normal 
healing  ;  the  latter  introduce  disease  into  the  process  of  healing,  the  most 
common  manifestation  of  which  is  the  condition  of  inflammation.1  A 

1  It  is  to  be  regretted  that  the  term  inflammation  has  been  separated  by  recent 
pathologists  from  its  traditional  use  to  denote  destructive  disturbances  of  repair  in 


MODIFIED    NORMAL    REPAIR.  29 

brief  consideration  must  be  given  to  the  phenomena  which  these  modify- 
ing circumstances  introduce  into  the  processes  of  repair. 

MODIFIED  NORMAL  KKPAIR. — In  injuries  in  which  apposition  is  imper- 
fect, but  in  which  all  sources  of  further  irritation  may  be  avoided  and  the 
conditions  that  favor  nutrition  can  be  secured,  an  apparent  modification 
of  the  healing  process  results  from  the  greater  amount  and  extent  of  the 
new  tissue  required  to  effect  repair,  but  the  process  is  essentially  the 
same.  Afflux,  exudation,  and  cell-germination  are  continued  until  the  gap 
is  filled  up ;  capillary  loops  are  continuously  extended  into  the  new 
material  as  it  is  formed,  and  a  progressive  transformation  of  it  into 
connective  tissue,  beginning  in  the  portions  first  formed,  takes  place. 
Numerous  granular  eminences  appear  on  the  superficial  layer  of  the  new 
material,  from  the  clustering  of  the  new  tissue  about  the  capillary  tufts. 
These  are  granulations,  in  technical  nomenclature,  and  the  new  tissue  is 
designated  as  granulation  tissue.  The  process  of  healing  thus  accom- 
plished is  termed  healing  by  granulation,  or  by  second  intention.  In  open 
wounds,  when  the  granulations  have  reached  the  level  of  the  cutis,  or  even 
sooner,  they  cease  to  grow ;  from  the  adjacent  margins  of  epidermis  a 
proliferation  of  epidermal  cells  takes  place,  which  forms  a  film  that  grad- 
ually spreads  over  the  granulating  surface,  forming  an  epidermal  covering 
which  completes  the  process  of  healing. 

If  surfaces  that  are  granulating  healthily  can  be  brought  and  retained 
in  contact  with  each  other,  prompt  and  permanent  adhesion  between 
them  will  take  place.  Union  thus  obtained  is  union  by  secondary  adhesion. 
or  third  intention. 

The  conditions  necessary  for  securing  the  undisturbed  production  and 
organization  of  granulation-tissue  are  most  frequently  secured  in  sub- 
cutaneous injuries,  in  which  cases  the  integument  serves  as  a  protection 
from  further  irritation,  and  especially  from  that  produced  by  the  floating 
organic  matter  of  the  air. 

They  may  also  be  sometimes  secured  in  open  wounds  which  expose  :i 
flat  surface  by  the  rapid  drying  of  the  substances  effused— blood  and 
lymph — on  the  surface,  so  as  quickly  to  produce  a  hard  crust  that  forms  :i 
nearly  impermeable  layer,  protecting  and  sealing  up  the  granulating  sur 


wounds  or  tissues,  and  has  been  extended  to  cover,  likewise,  all  the  processes  which 
attend  the  repair  of  wounds.  By  the  present  writer  it  will  be  used  only  in  the 
restricted  clinical  signification  which  was  given  to  it  by  the  older  writer*,  and  with 
which  it  is  still  used  by  practical  surgeons. 


30  THE    TREATMENT    OF    WOUNDS. 

face  beneath  from  further  irritation  until  its  cicatrization  is  completed. 
This  constitutes  healing  by  scabbing.  Though  frequent  in  the  repair  of 
open  wounds  in  animals,  the  greater  sensitiveness  to  irritation  possessed 
by  the  tissues  of  man  make  this  method  of  healing  applicable  in  him  to 
wounds  of  small  extent  only.  The  practical  difficulty  in  securing  the 
repair  of  open  wounds  is  to  protect  them  from  irritation.  Though  other 
sources  of  irritation  may  with  care  be  avoided,  the  deposition  upon  the 
wound  surfaces  or  in  the  wound  secretions  of  septic  germs  that  have 
been  floating  in  the  air  that  gains  access  to  it,  or  that  are  carried  by  the 
fluids  or  dressings  that  are  applied  to  it,  usually  quickly  takes  place. 
The  growth  of  these  germs,  under  the  most  favorable  circumstances,  pro- 
duces a  continuous  irritation  of  the  wound.  Whatever  the  source  of 
irritation,  its  immediate  result  is  exaggeration  of  the  pre-existing  active 
hypersemia,  excessive  exudation  of  plasma,  and  over-production  of  embry- 
onic cella  If  the  cells  be  in  excess  of  the  number  that  can  be  fixed  and 
organized  into  the  new  tissue,  they  are  floated  away  from  the  surface  of 
the  granulating  tissue,  suspended  in  the  liquid  plasma,  forming  a  yellow- 
ish, bland  liquid  that  bathes  the  free  surface  of  the  wound.  This  is 
pus ;  the  process  of  its  formation  constitutes  suppuration,  and  a  wound 
in  which  it  appears  is  a  suppurating  wound.  Pus  is,  therefore,  simply 
waste  embryonic  tissue  cast  off  from  a  granulating  surface  which  is  not 
perfectly  protected  from  irritation.  Its  production  is  not  a  necessary 
accompaniment  of  repair,  but  it  is  so  rarely  that  an  open  wound  can  be 
protected  so  perfectly  from  all  irritation  that,  practically,  suppuration  is 
to  be  considered  as  a  natural  attendant  upon  the  healing  of  open  wounds 
in  which  union  by  first  intention  is  not  secured.  The  free  escape  of  pus, 
as  formed,  is  important  to  be  secured,  for,  if  retained,  it  may  become 
itself  a  source  of  disturbance,  by  distention  of  the  wound-cavity,  and  by 
the  products  of  its  decomposition.  In  wounds  that  are  on  the  point  of 
healing  the  pus  becomes  thin  and  scanty,  and  when  the  surface  is 
exposed  to  desiccation  the  conclusion  of  the  healing  process  not  infre- 
quently takes  place  under  a  scab. 

Suppuration  involves  waste  of  the  new  material  furnished  for  repair 
and  entails  delay  in  the  completion  of  healing.  As  it  occurs  in  the 
ordinary  course  of  the  healing  of  an  open  wound  it  does  not  involve  the 
destruction  of  tissue. 

DISPOSITION  OK  EFFUSED  BLOOD  AXD  OF  DEAD  TISSUE. — The  extravasa- 
tions of  blood,  of  varying  amount,  and  the  portions  of  dead  tissue  which 


DISPOSITION    OF    BLOOD-CLOTS.  31 

an  injured  part  presents  as  the  direct  effect  of  the  injiny  may  modify  the 
process  of  repair.  In  subcutaneous  injuries  blood-extravasations,  to  some 
degree,  are  almost  always  present,  and  in  the  great  majority  of  open 
wounds  there  remains,  at  least  a  slight  layer  of  coagulated  blood  between 
the  wound  surfaces.  The  cavity  of  an  open  wound,  in  many  cases,  is 
filled  with  blood-clot,  like  a  plug.  Blood-clot  may  hinder  repair,  both  by 
mechanically  preventing  apposition  and  by  the  irritation  of  the  products 
of  its  decomposition  and  of  the  development  of  septic  germs,  to  which  it 
may  afford  a  nidus  for  multiplication.  In  subcutaneous  injuries  blood- 
clots  neither  decompose  nor  become  invaded  by  septic  germs.  When  the 
blood  is  infiltrated  into  the  connective-tissue  meshes  it  is  quickly  removed 
by  absorption  ;  when  it  remains  as  a  mass  filling  up  a  gap  between 
divided  tissues  it  serves  as  a  temporary  mould  for  the  support  of  the 
new  embryonic  tissue  that  is  to  form  the  permanent  bond  of  union.  The 
granulation  cells  produced  at  the  borders  of  the  divided  tissues  invade 
and  appropriate  its  substance,  capillary  vessels  follow  the  invading  cells, 
and  a  process  of  clot-absorption  and  granulation-tissue  development  con- 
tinues until  the  clot  has  disappeared  and  has  become  replaced  by 
cicatricial  tissue.  In  open  wounds,  when  apposition  of  the  divided  sur- 
faces can  be  secured  and  maintained,  any  slight  film  of  blood-clot  that 
may  be  present  will  not  perceptibly  interfere  with  the  repair,  but  will  b<; 
quickly  appropriated  by  the  germinating  tissue-cells,  and  will  disappear. 
In  open  wounds,  in  which  union  by  first  intention  is  impracticable,  if  the 
access  of  septic  germs  can  be  prevented  the  behavior  of  the  clot  is  the 
same  as  in  subcutaneous  wounds.  The  process  of  its  invasion  and  replace- 
ment by  granulation-tissue  gradually  extends  toward  its  surface,  till, 
after  some  days,  what  appears  to  be  the  dot  will  bleed  Avhen  scratched. 
More  frequently  the  superficial  layer  of  the  clot  remains  as  a  .somewhat 
dried,  dark-colored  stratum,  that  is  not  invaded  by  the  granulation-tissue, 
but  acts  as  a  protective  shield  to  the  deeper  parts  and  is  finally  exfoliated, 
scab-like,  when  the  cicatrization  of  the  tissue  underneath  is  nearly  or 
quite  complete.  In  open  wounds  which  are  not  kept  aseptic — and  these 
constitute  the  vast  majority  of  wounds — the  blood-dot  decomposes, 
liquefies,  and  is  washed  away  in  the  discharges  from  the  wound. 

In  all  wounds  there  is  devitalized  tissue  that  must  be  taken  care  of. 
The  removal  of  all  dead  tissue,  when  undisturbed  by  external  agencies,  is 
accomplished  by  the  same  processes  of  cell-invasion  and  appropriation  us 
has  been  described  as  the  active  agents  in  the  disposal  of  blood-clots. 


32  THE   TREATMENT    OF    WOUNDS. 

The  minute  particles  of  dead  tissue  which  exist  along  the  track  of  an 
incised  wound,  or  at  the  seat  of  a  mild  contusion,  are  quickly  absorbed, 
and  do  not  perceptibly  interfere  with  the  repair  of  the  injury.  Larger 
masses,  likewise,  if  they  can  be  kept  from  decomposition,  and  thus  from 
becoming  irritants,  may  be  gradually  removed  by  the  same  process  and 
their  place  taken  by  new  tissue.  Inasmuch  as  the  active  agents  in  the 
production  of  decomposition  are  minute  germs  that  float  in  the  atmos- 
phere, the  exclusion  of  these  germs  from  access  to  the  dead  tissue  is  of 
the  first  importance  in  promoting  repair  of  all  injuries.  When  the 
amount  of  dead  tissue  is  very  small,  and  the  other  conditions  for  active 
repair  are  supplied,  as  in  incised  wounds  in  which  apposition,  proper 
nutrition,  and  freedom  from  irritation  are  secured,  the  constructive  power 
of  the  living  tissue  is  sufficient  to  resist  the  destructive  tendency  of  the 
germs  that  may  have  gained  access  to  the  dead  molecules,  and  no  impedi- 
ment to  rapid  repair  is  suffered.  In  subcutaneous  injuries,  the  unbroken 
skin  forming  a  perfect  barrier  against  the  infection  of  the  injured  parts  by 
external  organisms,  the  removal  of  dead  tissue  by  absorption,  without  its 
becoming  a  source,  of  irritation  or  complicating  the  repair  of  the  injury 
in  any  other  way  than  by  mechanically  preventing  temporarily  the  appo- 
sition of  living  parts,  is  the  rule.  In  open  wounds,  or  in  injuries  that 
have  become  such  by  death  of  the  skin,  infection  of  the  dead  particles  or 
masses  and  their  conversion  into  irritants  through  decomposition  takes 
place.  The  reparative  efforts  at  the  line  of  junction  of  the  living  and  dead 
tissue  are  characterized  by  undue  and  prolonged  hypeneinia,  excessive 
exudation  of  plasma,  and  over-production  of  embryonic  cells.  The  new- 
formed  granulation  tissue  breaks  down  into  pus,  and  produces  thus  a 
solution  of  the  continuity  between  the  living  and  the  dead  parts.  The 
dead  part  thus  cast  off  is  called  a  slough.  The  rapidity  with  which  a 
slough  may  be  completely  cast  off  will  depend  upon  the  activity  of  the 
natural  nutritive  processes  of  the  particular  tissue  ;  the  separation  of  bone 
or  tendon,  for  example,  being  accomplished  much  more  tardily  than  that 
of  muscle  or  ordinary  connective-tissue.  When  the  surfaces  of  a  wound 
have  become  thus  freed  from  dead  tissue,  its  final  repair  will  be  accom- 
plished by  granulation  with  suppuration.  Injuries  which  have  been 
accompanied  with  much  crushing  and  tearing  are  complicated  not  only 
by  the  presence  of  parts  killed  outright  by  the  original  violence,  but, 
also  by  portions  of  tissue  whose  vitality  is  greatly  impaired,  that  are  half - 
killed.  Whatever  adds  to  the  irritation  of  the  original  injury,  or  interferes 


POSSIBILITIES    OF   NORMAL    REPAIR.  33 

with  the  after-nutrition  of  these  half-killed  parts,  endangers  still  more 
their  vitality,  and  their  absolute  death  may  be  determined  by  such  subse- 
quent conditions  at  any  period  of  the  reparative  process.  In  subcutaneous 
injuries,  and  in  open  wounds  that  are  kept  free  from  septic  infection,  the 
gradual  return  of  these  half-killed  tissues  to  their  normal  state  takes  place, 
and  the  repair  of  the  injury  is  accomplished  without  the  separation  of  any 
slough. 

A  review  of  the  processes  of  normal  repair  which  have  been  described 
shows  that,  when  uninterrupted  or  unimpaired  by  external  agencies  or 
by  unhealthy  constitutional  conditions,  they  are  competent  to  remove 
dead  tissue,  to  restore  vitality  to  partially  killed  tissue,  to  furnish  new 
material  to  repair  breaches  of  continuity,  and  to  accomplish  the  complete 
reorganization  of  this  new  material  into  living  tissue.  In  the  less  favorable 
conditions  which  those  open  wounds  present  in  which  the  access  of  atmos- 
pheric organisms  and  the  sloughing  of  dead  tissue  is  unavoidable,  as 
long  as  the  free  escape  of  the  decomposing  particles  and  of  the  pus  is 
possible,  and  further  injury  by  external  agencies  or  by  unhealthy  consti- 
tutional conditions  is  avoided,  uninterrupted  repair  still  takes  place,  but 
with  the  waste  of  much  reparative  material,  Avhich  escapes  as  pus  from  the 
exposed  surfaces. 

Though  the  processes  by  which  repair  is  effected  are  identical  in  all 
these  conditions,  the  practical  results  are  very  different  according  as  repair 
is  effected  without  or  with  suppuration.  When  repair  without  suppura- 
tion is  accomplished,  a  minimum  amount  of  new  tissue  is  required,  a 
minimum  disturbance  of  the  nutrition  and  the  function  of  the  injured 
part  is  suffered,  and  the  most  speedy  return  of  the  organ  to  its  functional 
activity  is  secured.  When  suppuration  attends  repair  the  process  of 
healing- is  prolonged,  a  greater  drain  upon  the  bodily  powers  is  produced, 
prolonged  disturbance  of  the  nutrition  and  function  of  parts  is  suffered, 
and  throughout  danger  of  disaster  from  accidental  complications  is  im- 
minent. When  repair  is  finally  accomplished  the  new  tissue  is  less 
highly  organized  than  that  which  it  has  replaced  and  permanent  impair- 
ment of  the  function  of  the  part  is  frequent. 

DESTRUCTIVE  DISTURBANCES  OF  BEPAIR. — The  turning-point  where  the 
processes  of  normal  repair  become  converted  into  processes  of  necrosis  is 
the  occurrence  of  prolonged  stasis  in  the  capillaries  of  the  wound  mar- 
gins. By  repeated  or  prolonged  irritation  of  the  already  injured  tissue— 
the  lower  the  vitality  of  the  tissue  the  less  the  irritation  needed— the  area 


34  THE   TREATMENT    OF    WOUNDS. 

of  the  primary  active  hypersemia  is  increased,  while  a  gradual  slowing  of 
the  blood-current  takes  place  in  the  vessels  which  are  nearest  to  the  point 
of  irritation,  until  finally  it  ceases  altogether,  although  at  the  periphery  of 
the  disturbed  region  the  conditions  of  vascular  dilatation  and  of  accelerated 
blood-flow  continue.  Simultaneously  with  the  retardation  the  white  cor- 
puscular elements  of  the  blood — leucocytes — begin  to  crowd  in  numbers 
against  the  walls  of  the  capillaries,  and  to  penetrate  them  by  their  amce- 
boid  properties,  and  to  accumulate  in  the  perivascular  tissue.  An  in- 
creased transudation  of  liquor  sanguinis  also  takes  place,  and  when  stasis 
finally  occurs  the  vessels  remain  choked  with  a  crowded  mass  of  red- 
blood  disks.  These  conditions  declare  themselves  by  increased  redness, 
heat,  swelling,  pain,  and  impairment  of  function  in  the  affected  part,  and 
by  more  or  less  fever.  A  part  presenting  these  symptoms  is  said  to  be 
inflamed,  and  the  condition,  as  a  whole,  constitutes  inflammation.1 

When  stasis  has  occurred  the  death  of  the  tissue  involved  is  immi- 
nent, but  if  further  injury  is  averted  and  the  general  conditions  favorable 
to  repair  are  furnished  the  stasis  may  shortly  be  overcome  and  the 
natural  course  of  the  circulation  be  resumed  ;  resolution  of  the  inflam- 
mation has  been  effected.  If,  however,  irritation  be  renewed  or  continued 
the  stasis  is  prolonged  and  local  death,  or  necrosis  of  tissue  takes  place. 

Inflammation  of  a  wound  involves,  therefore,  not  only  arrest  of  normal 
repair,  but  additional  destruction  of  tissue  ;  granulation  is  replaced  by 
ulceration,  and  a  new  element  of  disturbance  is  introduced  by  the  dead 
tissue  which  is  to  be  eliminated.  In  the  treatment  of  a  wound,  it  is 
important  that  inflammation  be  prevented,  or  that,  if  it  be  present  to  any 
degree,  its  resolution  be  gained,  and  its  destructive  effects  be  limited. 
Inflammation  is  always  due  to  some  "defect  of  protection  "  (see  page  28). 
When  a  wound  is  inflicted  upon  a  tissue,  the  injury  is  done  at  once  ;  the 
extent  and  duration  of  the  nutritive  disturbances  that  follow  are  limited 
by  the  extent  and  character  of  the  immediate  injury,  and  they  do  not 
reproduce  themselves  in  adjoining  healthy  tissues,  except  as  the  result  of 
new  injuries.  The  agents  of  injury  may  be  gross  or  minute,  may  produce 
their  effects  through  mechanical  violence  or  by  chemical  action,  may  be 
microscopic  germs  or  subtle  poisons,  but  they  all  have  the  common  effect 
of  impairing  the  vital  quality  of — i.e.,  injuring — the  tissues  they  come  in 
contact  with.  The  practical  fact,  however,  is  always  to  be  borne  in  mind, 

1  See  note  on  p.  28. 


CAUSES    OF   INFLAMMATION.  35 

that  the  effect  of  any  particular  injury  will  always  be  greatly  modified  by 
the  pre-existing  condition  of  the  tissue  acted  upon,  and  of  the  inherent 
resisting  quality  which  it  may  possess.  While  inflammation  is  present, 
the  healing  of  a  wound  is  arrested,  and  if  it  supervene  in  a  wound  in 
which  agglutination  has  already  taken  place,  the  new-formed  bond  melts 
down  and  the  wound  gapes,  presenting  red,  swollen,  and  everted  edges. 
The  local  diseases  of  wounds— erysipelas  and  gangrene — and  the  general 

blood  states  that  are  dependent  upon  wounds — pytsmia  and  septica3mia 

have  a  common  initial  lesion  in  wound-inflammation. 

To  prevent  or  to  limit  inflammation,  or  to  lessen  the  effects  of  the  dis- 
turbances induced  by  it,  appear,  therefore,  to  be  indications  of  the  greatest 
importance  to  be  met  in  the  treatment  that  a  wound  shall  receive.  The 
conditions  of  inflammation,  however,  do  not  arise  spontaneously,  nor  do 
they  perpetuate  themselves.  The  continuance  or  the  extension  of  an  in- 
flammation results  only  from  the  continued  or  extending  action  of  some 
irritant.  The  more  gross  ii-ritants,  as  motion,  friction,  or  other  mechan- 
ical violence,  or  ordinary  chemical  agents,  are  readily  detected,  and,  usu- 
ally, as  easily  guarded  against.  In  the  remarks  upon  classification  of 
wounds,  the  difference  in  the  behavior  of  subcutaneous  and  open  wounds, 
as  regards  their  liability  to  inflame,  was  mentioned,  and  the  inflammatory 
disturbances  likely  to  result  from  the  access  of  ordinary  air  noted.  "  Of 
the  two  injuries  inflicted  in  a  wound,  the  mechanical  disturbance  of  the 
parts  and  the  exposure  to  the  air  of  those  that  were  covered,  the  expo- 
sure, if  continued,  is  the  worse.  Both  are  apt  to  excite  inflammation  ; 
but  the  exposure  excites  it  most  certainly,  and  in  the  worse  form  ;  i.e., 
in  the  form  which  most  delays  the  process  of  repair,  and  which  is  most 
apt  to  endanger  life  "  (Paget).  It  was  still  further  noted  that  so  great 
was  the  difference  between  the  behavior  of  wounds  in  which  there  was 
much  devitalized  tissue  left  behind  by  the  wounding  agent,  and  those  in 
which  there  was  little,  that  it  constituted  a  basis  for  important  clinical 
classification.  That  the  mere  presence  of  devitalized  tissue  alone  is  not 
the  cause  of  these  disturbances,  however,  is  shown  by  the  fact  that  simi- 
lar injuries,  if  subcutaneous,  escape  them  in  great  measure.  The  men- 
presence  of  ordinary  air  alone  is  not  the  cause  of  these  disturbances, 
as  is  shown  by  the  harmlessness  of  surgical  emphysema,  and  the  freedom 
from  injury  exhibited  by  animals  through  whose  peritoneal  cavity  uufil- 
tered  ordinary  air  has  been  passed  for  hours.  The  only  conclusion  is 
that,  in  the  cases  in  question,  the  cause  of  inflammation,  and  of  the 


36  THE    TREATMENT    OF    WOUNDS. 

wound-diseases  that  are  associated  with  it,  is  to  to  be  found  in  the  mu- 
tual reaction  of  devitalized  tissue  and  some  agent  present  in  the  air. 
Wound- secretions,  when  accumulated  in  excess  of  that  which  can  at  once 
be  converted  into  living  tissue,  and  blood-clots,  are  but  forms  of  devital- 
ized tissue,  and  display  the  same  reaction  with  atmospheric  agents.  The 
importance,  therefore,  of  securing  the  most  complete  removal  of  blood- 
coagula  and  of  wound-secretions  from  wounds  that  are  to  be  left  exposed 
to  the  air,  depends  more  upon  the  inflammation-producing  reaction 
which  they  will  suffer  with  agents  brought  in  contact  with  them  by  the 
air,  than  it  does  by  the  defects  of  apposition  which  they  produce.  Sim- 
ple defects  of  apposition,  as  has  been  seen,  entail  only  prolonged  repair  ; 
the  decomposition  of  devitalized  tissue,  of  blood-clots,  and  of  wound- 
secretions  introduce  continuous  and  active  local  irritation,  and  bathe  the 
tissues  with  products,  the  absorption  of  which  into  the  circulation  poisons 
the  very  fountain  of  life. 

The  inflammation  which  complicates  the  repair  of  open  wounds  mani- 
fests varying  degrees  of  intensity,  and  of  tendency  to  extend  in  different 
cases.  It  may  be  limited  to  but  a  small  extent  of  tissue  adjacent  to 
the  wound-margins,  and,  with  the  separation  and  removal  of  the  shreddy 
sloughs  formed  by  the  dead  particles  of  tissue  originally  in  the  wound,  and 
of  the  liquified  blood-clots,  or  by  the  escape  of  the  accumulated  secretions, 
may  quickly  subside  and  permit  the  resumption  of  the  healing  of  the 
Avound  by  granulation.  It  may  diffuse  itself  upon  the  skin,  forming  a 
superficial  erysipelas,  or  may  extend  more  deeply  along  the  planes  of  con- 
nective tissue  that  may  have  been  opened  up  by  the  wound,  constituting 
a  diffuse  cellulitis  or  a  phlegmonous  erysipelas.  The  amount  of  necrosis 
also  may  present  every  grade  of  extent  from  that  of  molecular  disinte- 
gration upon  the  surface  of  the  wound  to  the  death  of  large  masses  of 
tissue.  The  amount  of  constitutional  disturbance  produced  by  the 
absorption  of  matters  generated  in  the  inflamed  tissue  varies  likewise 
from  a  slight  ephemeral  febrile  reaction  to  fatal  septicaemia  and  pynemia. 
It  is  not  in  the  scope  of  this  work  to  discuss  in  detail  the  various  phases 
of  the  destructive  disturbances  which  may  complicate  wounds.  Sufficient 
only  can  be  presented  to  serve  as  a  groundwork  upon  which  to  base  a 
rational  and  comprehensive  preventive  treatment,  for  the  treatment  of  a 
wound  cannot  be  considered  as  accomplished  until  all  the  possible  safe- 
guards against  the  disturbance  of  its  repair  have  been  secured. 


CHAPTER    III. 

THE    RELATIONS  OF    MICRO-ORGANISMS  TO    WOUND-DISTURB- 
ANCES. 

Results  of  Defects  of  Protection— Causes  of  Decomposition  of  Animal  Tissues— Re- 
searches of  Pasteur  and  Tyndall— Atmospheric  Organisms— Resisting-  Power  of 

Living  Tissues — Species  and  Generation  of  Micro-organisms— Bacteria— Bacilli 

Micrococci— Researches  of  Ogston,  Koch  and  others— Views  of  Hunt— Summary 
— Wound  Suppuration — Septicaemia  —  Pyaemia — Micrococcus-poisoning — Clinical 

Demonstrations — Results  of  the  Practice  of  Lister,  Volkmaun,  and  Nussbaum 

Comparative  Statistics  of  Amputations — Maceweu's  Osteotomies — Testimony  of 
Sands,  Stokes,  Cheyne,  and  Little — Resume. 

THE  importance  of  the  considerations  which  have  been  under  review 
in  the  preceding  chapter,  as  to  the  mechanism  of  healing  and  of  the  dis- 
turbances that  may  complicate  it  and  convert  its  beneficent  constructive 
processes  into  those  of  local  embarrassment  and  death,  and  of  possible 
general  danger,  have  their  greatest  demonstration  in  the  aid  which  they 
have  given  in  directing  a  search  for  the  ultimate  causes  of  the  changes 
that  result  in  disorders  of  repair.  Only  with  accurate  knowledge  of  these 
causes  can  intelligent  effort  to  prevent  their  access,  to  destroy  them,  or  to 
make  them  harmless  be  made.  Without  such  knowledge  wound-treat- 
ment is  an  empirical  groping  ;  with  it.  it  becomes  an  exact  science.  It 
has  been  seen  that  defects  of  reparative  power,  constitutional  and  local, 
may  hinder  repair  ;  that  defects  of  apposition  prolong  repair  and  occasion 
waste  of  reparative  material,  but  that  in  defects  of  protection  are  found 
the  conditions  that  produce  arrest  of  repair  and  destruction  of  tissue  ; 
that  the  defects  of  protection  which  occasion  the  most  frequent  and  most 
serious  wound-disturbances  are  those  which  permit  the  access  of  atmos- 
pheric air  to  wounds  ;  that  those  wounds  manifest  these  disturbances  in 
the  highest  degree  which  present  the  largest  amount  of  devitalized 
material ;  and,  finally,  that,  with  the  exception  of  the  transient  inflamma- 


38  THE    TREATMENT    OF    WOUNDS. 

tions  due  to  repeated  traumatism,  the  various  inflammatory  and  septic 
accidents  that  wounds  suffer  are  due  to  wound-decomposition. 

The  causes  of  the  decomposition  of  animal  tissues,  and  the  laws, 
methods,  and  products  of  their  activity,  must  therefore  be  regarded  by 
the  surgeon  as  matters  of  fundamental  importance  in  all  considerations  as 
to  the  treatment  which  he  shall  give  to  wounds.  As  to  the  causes  of 
decomposition  in  animal  tissues,  they  are  of  the  same  general  character 
as  those  which  determine  decomposition  or  fermenting  changes  in  organic 
matter  of  any  kind.  The  researches  of  Pasteur,  of  Tyndall,  and  their  co- 
laborers,  have  clearly  and  definitely  settled  the  scientific  truth  that  no 
decomposition  or  fermenting  change  will  take  place  in  organic  matter, 
except  after  the  introduction  into  it  from  without  of  living  organisms  that 
find  in  its  substance  pabulum  meet  for  their  nutrition,  and,  as  the  result 
of  their  multiplication  within  it,  induce  its  decomposition.  The  most 
frequent  and  universal  medium  by  which  these  organisms  or  their  germs 
are  brought  in  contact  with  material  susceptible  of  decomposition  is  the 
ordinary  air,  in  which  they  are  found  as  a  part  of  the  organic  matter  that 
constitutes  most  of  its  floating  dust.  Even  the  most  putrescible  sub- 
stances, as  urine,  and  animal  and  vegetable  infusions,  remain  unchanged 
for  an  indefinite  period  when  they  are  kept  in  an  atmosphere  which  is 
purified  from  organic  particles.  It  is  not  the  fully  developed  organism  that 
is  found  in  the  floating  matter  of  the  air,  but  minute  spores  or  germs  that 
require  to  be  planted  in  a  proper  soil,  and  to  be  surrounded  with  certain 
favorable  accessory  conditions  for  their  germination  and  growth  into  the 
fully  developed  organism  to  take  place.  The  matters  secreted  by  them  in 
their  development,  or  the  changes  inaugurated  by  their  vital  activity  as 
living  organisms,  determine  the  changes  in  the  substances  in  which  they 
multiply  which  constitute  decomposition,  putrefaction,  and  fermentation. 

Such  germinal  particles  "abound  in  every  pool,  stream,  and  river. 
All  parts  of  the  moist  earth  are  crowded  with  them.  Every  wetted  sur- 
face which  has  been  dried  by  the  sun  or  air  contains  upon  it  the  particles 
which  the  unevaporated  liquid  held  in  suspension.  From  such  surfaces 
they  are  detached  and  wafted  away,  their  universal  prevalence  in  the 
atmosphere  being  thus  accounted  for.  They  are  endowed  with  a  power 
of  flotation  commensurate  with  their  extreme  smallness  and  the  specific 
lightness  of  the  matter  of  which  they  are  composed  "  (Tyndall). 

Since  these  agents  of  decomposition  are  particles  and  not  gases,  they 
are  not  uniformly  diffused  through  the  atmosphere,  but  are  likely  to  be 


ATMOSPHERIC    ORGANISMS.  39 

more  numerous  wherever  and  whenever  the  conditions  that  favor  their 
growth  and  dissemination  are  active.1  This  implies  the  contrary  truth 
also,  that  at  times,  and  in  certain  conditions  that  promote  purity  of  the 
atmosphere,  indefinite  volumes  of  it  may  be  free  from  septic  germs 
altogether.  Particular  germs  of  the  same  species  differ  also  as  regards 
their  readiness  for  development ;  some  are  fresh,  others  old  ;  some  are  dry, 
others  moist.-  The  conditions  which  modify  the  germination  of  gross 
seeds  affect  in  an  equal  manner  these  minute  germs.  The  external  con- 
ditions of  warmth  and  moisture  hasten  their  development ;  cold  and 
absence  of  moisture  retard  it.  Of  the  greatest  importance,  however,  from 
its  power  in  limiting  their  disease-producing  effects,  is  the  power  with 
which  the  living  tissues  of  the  body  are  endowed  of  resisting  to  a  certain 
extent  the  action  of  these  germs,  and  of  destroying  them.  As  a  consequence 
of  this  these  organisms  are  never  found  in  the  fluids  or  tissues  of  the 
healthy  living  body,  notwithstanding  they  abound  in  the  air  by  which  it  is 
encompassed  ;  they  rest  and  develop  in  the  secretions  that  issue  on  the 
surfaces  and  gather  in  the  depressions  of  the  external  covering  of  the 
body,  and  they  swarm  in  the  secretions  and  contents  of  the  alimentary 
canal.  To  this  resisting  power  in  living  matter  is  due  the  fact  that  those 
germs  which  may  have  gained  access  to  the  tissues  exposed  by  a  wound, 
do  not  develop  and  multiply  and  produce  decomposition  in  such  a  wound 
when  speedy  and  complete  contact  of  its  surfaces  is  secured  and  main- 
tained. On  the  contrary,  whatever  germs  may  be  present  in  such  a  wound 
are  killed  by  contact  with  the  living  cells  that  are  active  for  its  repair. 
Should,  however,  the  coaptation  of  the  wound-surfaces  be  imperfect,  so 
that  recesses  or  cavities  remain  in  which  fluid  exudates  accumulate,  the 
best  of  conditions  are  afforded  at  once  for  the  development  of  whatever 
germs  might  have  gained  access  to  them. 


1 M.  Miquel's  experiments  at  the  observatory  at  Montsouris  in  Paris,  show  that 
they  are  most  numerous  in  the  lower  strata  of  the  air.  While  in  a  cubic  metre  of 
air  at  the  top  of  the  Pantheon  he  found  but  twenty-eight  of  them,  the  same  quan- 
tity of  air  in  the  park  of  Montsouris  contained  forty-five,  and  in  the  mairie  of  the 
fourth  arrondissement,  four  hundred  and  sixty-two.  Great  agglomerations  of  men 
furnish  the  most  of  them.  The  air  in  the  interior  of  Paris  is  nine  or  ten  times  richer 
'in  them  than  that  in  the  neighborhood  of  the  fortifications.  The  dusts  proceeding 
from  substances  in  a  state  of  putrefaction,  unhealthy  pus,  and  the  dejections  of  the 
sick,  are  charged  with  them.  After  two  or  three  days  of  moist  and  rainy  weather, 
the  atmosphere  is  in  a  condition  of  extreme  purity. 


40  TUB    TREATMENT    OF    WOUNDS. 

Much  still  remains  to  be  determined  with  regard  to  the  disease-pro- 
ducing possibilities  of  the  germs  that  in  invisible  clouds  drift  in  the  at- 
mosphere. We  are  as  yet  only  on  the  threshold  of  knowledge  with  regard 
to  them.  The  extreme  minuteness  of  the  organisms  themselves,  and  the 
still  more  minute  character  of  the  germs  by  which  they  are  disseminated, 
make  their  isolation  and  study  one  of  great  difficulty,  and  one  especially 
liable  to  errors.  The  more  delicate  and  exact  methods  of  the  most  recent 
observers— Koch,  Pasteur,  Tyndall,  Ehrlich,  Ogston,  Sternberg,  and  others 
— with  regard  to  their  nature,  seem  to  show  that  there  are  many  species 
of  them,  each  of  which  has  its  own  conditions  of  growth,  requiring,  or  de- 
veloping best  in,  a  particular  soil,  different  species  multiplying  in  differ- 
ent media,  arid  varying  in  their  susceptibility  to  different  temperatures 
and  to  different  chemical  reagents.  Apparent  identity  of  form  does  not 
necessarily  indicate  identity  of  nature.  They  are  not  convertible  into 
each  other ;  each  species  produces  only  itself,  and  is  produced  by  itself 
alone,  and,  when  introduced  into  a  substance  that  affords  a  favorable  soil 
for  its  growth,  always  produces  in  it  the  same  results.  These  results  are 
not  produced  suddenly,  but  are  of  gradual  development,  progressing  pari 
passu  with  the  slow  and  steady  multiplication  of  the  organism.  In  addi- 
tion to  the  immediate  and  direct  effect  of  the  multiplying  mici-o-organism, 
chemical  changes,  for  the  inauguration  of  which  the  organisms  were 
necessary,  after  having  been  once  set  in  motion  by  them,  may  continue  to 
advance  after  the  activity  of  the  organism  has  ceased. 

The  species  of  micro-organisms  that  have  been  identified  as  capable  of 
producing  disease  in  the  human  body  are  comparatively  few  in  number. 
Of  these,  the  ones  that  are  concerned  in  the  production  of  the  inflamma- 
tions and  infectious  diseases  that  complicate  wounds  are  embraced  in  two 

i 

great  groups,  viz.  :  spherical  organisms,  or  micrococci,  and  rod-shaped 
organisms,  which  include  bacteria '  and  bacilli,  the  term  bacteria  being 
applied  to  slightly  oval  or  sausage-shaped  organisms,  and  bacilli  to  the 
more  slender  rods.  The  characteristic  appearance  of  these  forms  is  well 
shown  in  the  accompanying  cut  (Fig.  1),  in  which  all  three  forms  appear 
as  present  in  the  discharges  from  a  case  of  compound  dislocation  of  the 
thumb,  in  which  no  attempt  to  prevent  their  development  had  been  made 
(see  Cheyne,  "Antiseptic  Surgery,"  p.  235,  Case  1). 


1  The  term  bacteria,  though  originally  applied  to  all  forms  of  micro-organisms,  has 
become  restricted  to  the  special  form  noted  in  the  text. 


MICRO-ORGANISMS    IN    WOUNDS. 


41 


The  conditions  in  which  these  different  forms  of  organisms  flourish  dif- 
fer, and  the  results,  in  general,  determined  by  them  also  differ.  In  every 
wound  which  smells  suspiciously  the  rod-shaped  organisms  are  present  in 
large  numbers.  Where  a  bagging  wound  or  a  deep  sinus  is  present,  the 
discharge  is  apt  to  be  fetid  and  contains  mostly  the  rod-shaped  organisms ; 
but  when  an  incision  converts  the  pouch  into  a  superficial  wound,  the 
spherical  organisms  again  become  predominant  (Ogston1)  ;  and  in  the  dis- 
charges which  flow  from  flat  surfaces  in  general,  where  stagnation  is 
avoided,  the  spheres  exist  in  preponderating  numbers.  The  conclusion  is 
that  the  character  of  the  decompositions  determined  by  the  growth  of 


FIG.  1.—  The  Micro-organisms  of  Septic  Wound 


K  (enlarged  from  Cftei/ue). 


these  different  micro-organisms  are  not  identical,  but  that  each,  in  feeding 
QU  the  soils  in  which  they  are  sustained,  generates  different  changes  in  the 
substances  where  they  grow.  The  bacteria  as  a  class,  and  some  bacilli  as 
well,  produce  the  decompositions  of  putrefaction,  i.e.,  those  in  which  the 
substances  evolved  have  an  offensive  stench.  If  the  contents  of  an  abscess, 
or  a  fluid  where  organisms  have  been  growing  be  found  to  present  a  pu- 
trid smell,  we  are  absolutely  certain  to  detect  in  it  numerous  organisms 
that  possess  either  the  sausage-shape  of  the  bacterium  or  the  rod  of  the 
bacillus  (Ogston).  The  more  putrid  the  discharge  the  more  numerous 
and  the  smaller  the  bacteria  (Cheyne).  The  vital  energy  of  these  <>r- 


1  Report  upon  Micro-Organisms  in  Surgical  Diseases.     By  Alexander  Ogston,  M.  U. 
British  Medical  Journal,  March  12,  1881. 


42  THE    TREATMENT    OF    WOUNDS. 

ganisms  of  putridity  is  weak  ;  they  are  quickly  killed  by  weak  antiseptic 
agents  ;  they  do  not  survive,  much  less  grow  in  the  blood  ;  they  do 
not  invade  living  tissue,  but  attack  only  dead  tissue,  and  when  they 
affect  the  general  system  it  is  by  the  absorption  into  the  blood  of  the  pu- 
trid liquids  and  gases  that  are  generated  at  the  original  site  of  putrefac- 
tion. The  septicaemia  that  is  produced  depends  for  its  continuance  upon 
the  continued  activity  of  the  local  putrefactive  process,  and  disappears 
when  this  external  supply  is  stopped.  Wounds  containing  much  putre- 
fiable  material,  when  they  are  at  the  same  time  of  such  a  character  as  to 
hinder  the  ready  escape  of  the  wound-secretions,  afford  the  most  perfect 
conditions  for  the  luxuriant  development  of  these  organisms.  The  removal 
of  sloughs,  the  opening  of  sinuses,  and  the  establishment  of  free  outlets  for 
the  secretions,  tend  to  banish  the  organisms  by  removing  the  pabulum 
necessary  for  their  existence. 

The  spherical  organisms — micrococci — manifest  characteristics  quite 
different  from  those  displayed  by  the  rod-shaped,  and  exhibit  a  relation  to 
wound-disturbances  much  more  extended  and  difficult  to  control.  Micro- 
cocci  are  described  by  Cheyne  as  colorless  or  colored  round  cells,  very 
small,  generally  under  one  micro-millimetre  in  diameter,  with  or  without 
movement,  growing  in  pairs,  short  chains,  or  groups  of  smaller  or  larger 
size,  this  cycle  being  repeated  on  the  addition  of  fresh  pabulum.  In  a 
given  specimen  of  pus  they  will  not  be  uniformly  distributed,  and  they  will 
vary  in  size,  while  in  different  specimens  their  numbers  may  vary  greatly. 
One  specimen  of  pus  examined  by  Ogston  contained  forty-five  millions 
per  cubic  millimetre,  while  two  others  contained  •  in  the  same  bulk  only 
nine  hundred.  The  decompositions  that  they  induce  are  not  those  of 
common  putridity.  If  they  are  introduced  into  a  fluid  and  there  culti- 
vated they  produce  no  offensive  stench.  In  most  acute  abscesses  where 
they  abound  no  bad  odor  is  detectable,  and  in  general  their  presence  or 
absence  is  not  indicated  .by  any  smell.  The  observations  of  different 
investigators  indicate  that  there  are  different  species  of  micrococci,  some 
comparatively  innocuous,  others  extremely  virulent.  "  Some  are  patho- 
genic and  others  are  not ;  some  develop  in  the  blood  of  certain  animals 
and  others  will  not.  Different  species  multiply  in  different  media,  and  are 
destroyed  at  different  temperatures.  A  nutrient  medium  which  has  been 
exhausted  for  one  micrococcus  may  not  be  exhausted  for  another  "  (Stem- 
berg).  Cheyne  describes  certain  micrococci  as  existing  in  wounds,  even 
in  large  numbers,  without  apparent  ill  effect  beyond  causing  a  sort  of 


MICROCOCCI.  . 


43 


sour,  sweaty  smell  in  its  fluids.  Ogston  found  micrococci  in  the  pus  of 
all  acute  abscesses,  and  in  wounds,  in  amount  and  activity  proportionate  to 
the  intensity  of  the  suppuration ;  but  a  marked  difference  was  found  to 
result  in  the  results  of  injections  made  into  the  tissues  of  mice  with  the 
pus  of  abscesses  and  the  pus  of  wounds.  With  the  first,  with  rare  excep- 
tions, well-marked  disease,  either  rapidly  fatal  blood-poisoning,  or  local 
sphacelus,  or  acute  inflammation,  accompanied  by  blood-poisoning  and 


0«3 


Fia.  2.— Group  of  Chain  Micrococci  (Ogston). 

ending  in  abscess,  followed.  With  the  latter,  that  of  wounds,  though  rich 
enough  in  micrococci,  it  was  with  difficulty  that  an  occasional  suppuration 
was  produced.  This  observer  further  describes1  two  distinct  forms  of 
micrococci,  among  the  more  virulent  organisms,  chains  and  groups  (Figs.  2 
and  3),  which  though  often  found  together,  were  different  organisms  ;  the 
chain  form  never  passing  into  the  grouped  form,  nor  the  grouped  form  into 
the  chain.  Both  possess  the  power  of  causing  inflammation  ending  in 
suppuration,  and  both  cause  phlegmons.  But  the  i.iore  disease  approaches 
the  erysipelatous  type  and  concentrates  itself  in  the  lymphatics,  the  more 
evident  does  its  connection  with  the  chain  form  become  ;  while  suppurative 
inflammation,  expending  itself  on  the  tissues  rather  than  on  the  lymphatics, 
seems  to  be  the  characteristic  result  of  the  grouped  form.  Fehleisen,  of 


1  Micrococcus  Poisoning.     By  Alexander  Ogston,  M.  D.     Journal  of  Anatomy  and 
Physiology,  vols.  xii.  and  xiii. 


44  THE    TREATMENT    OF    WOUNDS. 

Berlin,  has  demonstrated  by  direct  proof  the  agency  of  chain  micrococci 
in  the  production  of  erysipelas.  This  observer  not  only  found  them  pres- 
ent in  all  cases  of  erysipelas  which  he  examined  during  life,  but,  also 
cultivated  them,  and  with  equal  success  inoculated  the  cultivated  organ- 
isms in  animals  and  in  man.1  By  planting  small  pieces  of  the  excised 
erysipelatous  skin  in  gelatine,  he  inaugurated  a  series  of  cultivations,  by 


FIG.  3. — Grouped  Micrococci  invading  Abscess  Wall  (Ogxton). 

which  films  consisting  entirely  of  the  specific  micrococcus  were  obtained. 
Of  seven  men  whom  he  inoculated  with  the  micrococci  thus  isolated,  six 
showed,  after  a  period  of  incubation  ranging  from  fifteen  to  sixty  hours, 
typical  erysipelas,  setting  in  with  rigors,  high  temperature,  and  running 
the  characteristic  course. 

Koch  *  describes  a  micrococcus  that  whenever  it  was  introduced  into 
the  tissues  of  mice  produced  a  spreading  gangrene  that  extended  continu- 
ously until  it  killed  the  animals.  The  inflammation,  suppuration,  and 


'  Die  Aetiologie  des  Erysipels.     Berlin,  1883. 

*  Investigations  into  the  Etiology  of  Traumatic  Infective  Diseases.  By  Dr. 
Robert  Koch  (Wollstein).  Translated  by  W.  Watson  Cheyne,  F.R.C.S.  London:  The 
New  Sydenham  Society,  1880. 


MICROCOCCI    AND    SUPPURATION.  45 

gangrene  produced  by  micrococci  cannot  with  reason  be  referred  to  any 
mechanical  effect  from  their  presence.  Koch  explains  the  gangrene- 
producing  effects  of  the  organisms  investigated  by  him,  as  follows  :  "  In- 
troduced by  inoculation  into  li ving  animal  tissues,  they  multiply,  and  as  a 
part  of  their  vegetative  process  they  excrete  soluble  substances  which  get 
into  the  surrounding  tissues  by  diffusion.  When  greatly  concentrated,  us 
in  the  neighborhood  of  the  micrococci,  this  product  of  the  organisms  has 
such  a  deleterious  action  on  the  cells  that  these  perish,  and  finally  com- 
pletely disappear.  At  a  greater  distance  from  the  micrococci  the  poison 
becomes  more  diluted  and  acts  less  intensely,  only  producing  inflammation 
and  accumulation  of  lymph  corpuscles." 

Ogston,  likewise,  concludes  that  it  must  be  by  the  noxious  substances 
generated  during  their  growth  that  they  irritate  the  tissues,  and  cause 
inflammation  and  suppuration.  "It  maybe  looked  upon,"  he  says,  "as 
being  far  from  unlikely  that  'the  very  reason  why  micrococci  produce  sup- 
puration is  that  they,  in  growing  among  the  tissues,  generate  some  acrid 
ptomaines  that  may  correspond  pretty  closely  in  their  effects  with  those  of 
injections  of  tiu-pentine  or  other  caustic  liquid." 

Belfield,1  after  referring  to  the  experiments  of  Pasteur,  in  which  a 
previously  harmless  culture  fluid,  when  it  had  become  swarming  with 
micrococci  by  the  multiplication  within  it  of  a  micrococcus  found  in 
ordinary  water,  was  invariably  followed,  in  the  rabbit,  by  suppuration 
around  the  point  of  injection,  the  pus  and  tissues  containing  numbers  of 
the  same  organisms ;  and  to  the  observations  of  Klebs,  Zahn,  and  Tiegel, 
who  found  that  while  the  injection  of  pus  from  a  pysemic  abscess  or  putrid 
fluid  was  followed  by  local  suppuration  and  multiple  abscess  formation  in 
the  infected  animal,  the  same  pus  or  liquid,  after  filtration  through  clay 
cylinders — whereby  the  micro-organisms  were  separated  from  the  liquid- 
caused  intense  general  infection,  but  no  suppuration,  even  at  the  point  of 
injection  ;  and  to  the  observation  of  Koch  that  infectious  suppuration  in 
the  rabbit  after  putrid  inoculation  was  constantly  associated  with  a  charac- 
teristic micrococcus,  says  :  "It  appears,  therefore,  impossible  to  evade 
the  conclusion  that  suppuration  can  be,  and  is  induced  by  micrococc-i. 
That  this  effect  is  induced  by  one  or  more  specific  varieties  of  these  organ- 
isms seems  probable  from  these  researches  of  Klebs,  Koch,  and  Pasteur  ; 


1  On  the  Relations  of  Micro-Organisms  to  Disease.    By  William  T.  Belfield,  M.D. 
The  Medical  Record,  March  3,  1883,  p.  228. 


46  THE   TREATMENT    OP    WOUNDS. 

that  it  is  not  induced  by  all  species  is  apparent  from  the  fact  that  colonies 
of  micrococci  are  frequently  present  in  the  human  and  other  animals 
during  various  morbid  processes  in  which  suppuration  does  not  occur — as 
in  erysipelas.  As  to  the  mode  in  which  this  influence  is  exerted,  there  is 
no  definite  knowledge  ;  the  assumption  that  the  deleterious  effect  results 
from  changes  in  the  chemical  constitution  of  the  containing  medium,  as  an 
essential  feature  of  the  vital  activity  of  these  organisms,  is  supported  by 
analogy  with  the  processes  of  fermentation  and  putrefaction,  by  the  phen- 
omena known  to  attend  the  life  of  other  bacteria,  and  by  the  direct 
observations  of  Koch  and  Pasteur." 

The  relation  of  micrococci  to  suppurative  inflammations  is  one  of  great 
interest  and  importance  in  its  bearing  upon  the  healing  of  wounds.  While 
— as  has  been  seen — not  all  forms  of  micrococci  are  capable  of  exciting 
suppuration,  nor  are  micrococci  the  only  agents  that  are  competent  to 
excite  suppuration,  yet  the  proof  seems  strong  that  the  suppurations  and 
Buppurative  diseases  that  complicate  wounds,  and  the  acute  suppurative 
inflammations  that  occur  in  man  are  caused  by  the  vital  activity  of  some 
form  of  micrococcus.  The  observations  of  Ogstou,  in  which  the  pres- 
ence of  micrococci  in  the  pus  of  all  acute  abscesses,  and  in  that  formed  in 
wounds,  have  already  been  referred  to.  The  negative  observations  of  the 
same  investigator  are  also  to  be  considered  with  these,  that  in  wounds  in 
which  no  micrococci  could  be  discovered,  no  pus  was  produced,  but  the 
discharge  remained  serous ;  and  that  in  all  cases  in  which,  by  his  method 
of  dressing  wounds,  the  access  of  micro-organisms  from  without  was 
guarded  against,  both  micrococci  and  suppuration  remained  absent. 
When,  however,  wounds  suppurated,  the  intensity  of  the  suppuration  was 
proportionate  to  the  numbers  and  activity  of  the  micrococci,  which  not 
only  multiplied  in  the  wound-secretions,  but  also  infiltrated  the  adjacent 
tissues,  until,  by  the  formation  of  a  dense  layer  of  granulation-tissue,  their 
f  ui-ther  invasion  was  limited.  The  chain  of  proof  that  the  micrococci  are 
the  essential  causes  of  the  suppuration  is  rendered  nearly  complete  by  the 
results  of  inoculation  experiments,  by  which  it  has  been  shown  that  pus 
devoid  of  organisms,  as  in  that  of  chronic  abscesses,  or  pus  whose  organ- 
isms have  been  killed  by  carbolic  acid  or  high  temperatures,  is  harmless 
when  injected  into  the  tissues  of  animals,  while  pus  that  contained  micro- 
cocci,  when  injected,  in  doses  of  a  minim  or  more,  invariably  occasions 
well-marked  disease,  comprising,  as  a  general  rule,  acute  local  inflamma- 
tion accompanied  by  blood-poisoning  and  ending  in  abscess. 


HUNT    ON    MICRO-ORGANISMS.  47 

The  experimental  proof  is  continually  accumulating  that  the  various 
inflammatory  disturbances  that  embarrass  the  healing  of  wounds  are  due, 
with  but  few — and  these  easily  recognizable— exceptions,  to  the  results  of 
the  vital  activity  of  micro-organisms.  Nevertheless,  many  still  demur 
that  the  proof  is  not  sufficiently  positive  that  the  organisms  are  the  spe- 
cific and  primary  cause  of  the  irritation  that  determines  the  inflammatory 
disturbances,  but  that  a  possibility  exists  that,  after  all,  they  may  be  sim- 
ply the  concomitants  of  conditions  that  have  determined  the  inflammation, 
conditions  the  exact  character  of  which  has  as  yet  eluded  our  search. 
Perhaps  no  better  putting  of  such  objection  has  been  phrased  than  that 
of  Dr.  William  Hunt,  Senior  Surgeon  to  the  Pennsylvania  Hospital,  in  the 
address  delivered  by  him  before  the  Philadelphia  Academy  of  Surgery, 
January  8,  1883.  In  this  address  he  speaks  as  follows  : '  "  Now,  are  the 
plaguing  micro-organisms,  of  which  we  hear  so  much,  any  more  than  con- 
sumers of  dead  material,  serving  (as  we  find  them  everywhere)  a  beneficent 
end  so  long  as  they  do  not  get  into  the  ivrong  places  ?  Molecular  death 
is  going  on  continuously  in  all  living  tissues.  In  the  nice  balance  of  per- 
fect health,  the  results  are  removed  so  completely  through  the  blood  and 
lymph  channels,  and  by  other  means,  that  there  is  no  accumulation. 
When,  however,  disturbances  arise,  as  inflammations,  for  example,  from 
any  cause,  abundant  necrotic  products  are  the  consequence,  and  these  ac- 
cumulate faster  than  they  can  be  removed.  Then  come  in  the  migratory 
micro-organisms.  It  is  a  question  of  food,  and  is  consonant  with  what 
we  know  of  the  movements  of  hosts  of  higher  animals,  possibly  also  of 
plants,  and  sometimes  of  man  himself.  As  these  organisms  get  into  the 
wrong  places,  they,  accumulating  with  great  rapidity,  help  to  choke  fur- 
ther and  irritate  what  has  already  started  on  an  evil  course,  and  so  they 
become  secondary  and  very  fruitful  causes  of  disease.'' 

In  this  view,  so  attractively  and  ingeniously  set  forth,  of  the  relation 
of  micro-organisms  to  wound  disturbances,  the  relation  of  the  micro- 
organisms to  the  changes  in  the  necrotic  products,  by  which  these  become 
inflammation-producing  agents,  is  lost  sight  of,  and  the  only  evils  recog- 
nized as  resulting  from  the  presence  of  the  micro-organisms  are  those 
simply  which  the  accumulation  of  the  organisms  themselves  in  wrong 
places  may  be  capable  of  determining.  The  sequence  of  events  which  is 
claimed  is  :  1,  inflammation,  from  some  cause  ;  2,  accumulation  of  ne- 


Medical  News,  p.  93,  January  27,  1883. 


48  THE    TREATMENT   OF 

erotic  products  ;  3,  micro-organisms.  If  we  test  this  order  by  the  se- 
quence of  events  which  occur  in  a  wound  that  has  become  inflamed,  in 
which  case  the  causes  of  the  inflammation  may  be  followed  accurately 
with  more  ease  than  in  the  case  of  internal  inflammations,  the  error  of  the 
view  becomes  apparent. 

In  the  case  of  a  wound,  the  injury  sustained  by  the  wounded  tissue 
does  not  involve  new  tissue  after  the  injuring  agent  has  ceased  its  action. 
The  tissues  in  which  vitality  remains  proceed  at  once  to  efforts  at  repair, 
which  process,  modified  in  its  activity  only  by  the  local  and  constitu- 
tional vigor  of  the  individual,  progresses  regularly  to  its  termination,  pro- 
vided new  sources  of  injury  ai-e  not  added.  The  presence  of  the  devital- 
ized tissue,  resulting  from  the  original  injury,  embarrasses  the  process  of 
repair  only  mechanically  until  it  is  absorbed,  or  otherwise  removed,  as 
long  as  it  is  preserved  from  putrefactive  changes.  Putrefaction  results, 
and  results  only,  from  the  introduction  into  the  devitalized  tissue  of  such 
micro-organisms  as  find  in  it  a  suitable  medium  for  their  active  growth 
and  multiplication.  As  a  result  of  their  action  the  devitalized  tissues  be- 
come irritants  that  add  new  and  continuously  acting  injury  to  the  parts 
with  which  they  are  in  contact,  the  final  outcome  of  which  is  the  condition 
which  a  surgeon  terms  inflammation — a  condition  which  will  persist  and 
spread  until  in  some  way  the  source  of  irritation  is  eliminated  or  isolated. 
The  case,  then,  as  observed  in  wounds,  may  be  summed  up  briefly  some- 
what in  this  way  :  Inflammation  is  always  the  result  of  continued  irrita- 
tion ;  devitalized  tissue,  in  itself,  in  whatever  quantities,  is  unirritating  ; 
therefore  the  accumulation  of  devitalized  tissue  is  not  a  cavise  of  inflamma- 
tion. Devitalized  tissue  in  which  micro-organisms  are  growing  and  multi- 
plying is  irritant,  and  prone  to  excite  inflammation  ;  the  new  and  specific 
element  which  has  been  added,  and  from  which  the  irritant  qualities 
spring,  are  the  micro-organisms  ;  therefore,  from  the  point  of  view  of  the 
inflammation,  they  are  its  specific  and  primary  cause.  The  order,  there- 
fore, of  the  sequence  of  the  conditions  which  determine  inflammation  in  a 
tissue  is  not  that  of  the  author  to  whom  reference  has  been  made,  but  is  the 
exact  reverse,  viz.:  1,  micro-organisms;  2,  necrotic  products;  3,  inflammation. 

It  is  hardly  necessary  to  observe  that  this  discussion  applies  equally  to 
the  causes  of  the  suppuration  which  usually  accompanies  the  healing  of 
wounds  by  granulation,  for  the  production  of  pus  upon  a  wound  surface  is 
the  result  of  irritation  of  that  surface,  and  depends  for  its  continuance 
upon  a  condition  of  the  tissues  alike  in  kind,  and  differing  only  in  degree 


MICRO-ORGANISMS   AND    SEPTICAEMIA.  49 

aiid  extent  from  that  which  constitutes  inflammation,  in  the  surgical  sense 
of  the  word.  The  products  of  the  ordinary  micrococcus,  as  it  multiplies  in 
the  secretions  of  a  wound  on  whose  surface  it  has  been  deposited,  are  but 
little  irritating,  as  has  been  shown  by  its  feebly  noxious  effects  when  in- 
jected into  the  tissues  of  living  animals ;  but  it  is  sufficient  to  provoke  the 
prolonged  hypersemia,  the  overflow  of  plasma,  and  the  excessive  produc- 
tion of  cells  that  constitute  suppuration. 

Thus  far  in  the  consideration  of  the  relations  of  micro-organisms  to 
wound-disturbances,  a  brief  outline  only  of  the  knowledge  which  has  thus 
far  accumulated  as  to  their  local  effects  has  been  attempted.  It  has  been 
seen  that  positive  proof  has  been  furnished  that  in  many  cases  suppura- 
tion, phlegmonous  inflammation,  gangrene,  and  erysipelas  have  been  the 
direct  result  of  the  vital  activity  of  certain  forms  of  micro-organisms,  and 
that  a  strong  presumption  has  been  established  that  the  same  relation  of 
cause  and  effect  existed  in  general.  Incidentally  reference  has  been  made 
to  the  effects  produced  upon  the  whole  system  by  the  absorption  into  the 
blood  of  the  noxious  products  or  ptomaines  that  result  from  the  changes 
in  the  pabulum  upon  which  they  feed,  to  which  the  general  term  Septiccv- 
mia  is  applicable.  This  demands  farther  consideration,  and  also  the 
closely  allied  state  in  which,  with  a  septic  condition  of  the  blood,  there  is 
associated  multiple  abscesses  in  various  organs  of  the  body,  Pyaemia. 

Blood-poisoning  and  inetastatic  abscesses  claim  recognition  as  the  most 
redoubtable  processes  that  can  complicate  the  healing  of  wounds.  Their 
close  association  with  faults  of  repair  in  wounds,  and  the  development  of 
unhealthy  conditions  in  the  wound-secretions  have  always  been  too  dis- 
tinct to  fail  of  recognition,  so  that  the  clinical  fact  that  these  processes 
were  consequent  upon  the  absorption  of  noxious  or  septic  matters  pro- 
duced in  the  wrounds,  was  long  appreciated  before  experimental  investiga- 
tion attempted  to  determine  and  isolate  the  essential  cause  of  their  hurtful 
character.  Belfield,  in  his  lecture  on  sepsis  and  antiseptic  sui-gery,1  gives 
a  summary  of  the  experimental  researches  that  have  been  made  as  to  the 
nature  and  method  of  working  of  the  septic  elements,  the  more  important 
results  of  which  are  those  obtained  by  Panum,  Billroth,  Bergmann,  and 
others,  which  established  the  fact  that  the  clinical  and  anatomical  fea- 
tures of  septicaemia  could  be  induced  by  unorganized  siibstances  obtained 
from  the  products  of  putrefaction,  though  in  these  cases  two  character- 


The  Medical  Record.  March  3,  1883,  p.  225. 


50  THE    TREATMENT   OF    WOUNDS. 

istics,  frequently  observed  in  the  septic  infection  of  human  subjects,  were 
often  conspicuously  absent — the  stage  of  incubation  and  the  infectiousness 
of  the  septic  blood  and  tissues  ;  those  of  Klebs,  by  which  it  was  shown 
that  the  injection  of  putrid  liquids  containing  myriads  of  micro-organ- 
isms was  followed  by  continuous  fever  and  metastatic  abscesses,  while 
the  injection  of  the  same  liquids  after  they  had  been  deprived  of  their 
solid  particles,  including  organisms,  by  filtering  through  clay,  was  fol- 
lowed by  fever  just  as  intense,  though  transient,  but  never  by  nietastutic 
abscesses  ;  those  of  Pasteur,  in  which,  in  animals  that  had  become  septi- 
cally  infected,  there  were  always  found  present  micro-organisms  in  the 
serous  sacs,  muscles,  liver,  and  spleen,  although  the  blood  may  have  been 
free  from  them  until  death — a  drop  of  peritoneal  serum,  or  a  piece  of 
muscle  from  an  animal  dead  of  sepsis  induced  in  a  second  animal  all  the 
appearances,  ante-  and  post-mortem,  of  the  original  disease,  while  a  drop 
of  blood  from  the  heart-cavity,  proven  microscopically  to  contain  no  septic 
vibrios,  was  innocuous  ;  and  the  crowning  experiments  of  Koch,  Gaffky, 
and  Loftier,  in  which  the  particular  bacilli  of  septicaemia  in  mice,  micro- 
cocci  of  spreading  gangrene  in  mice,  bacteria  of  septicaemia  in  rabbits, 
and  micrococci  of  pyaemia  in  rabbits,  were  completely  isolated  from  the 
animal  tissues  by  cultivation  upon  solids,  and,  thus  isolated,  reintroduced 
into  healthy  animals  with  the  reproduction  of  the  same  diseases  as  that 
which  had  before  been  produced  when  the  original  infected  blood  was 
inoculated.  The  author  from  whom  we  quote  sums  up  the  case  as  follows  : 
"  A  review  of  the  evidence  already  considered  shows,  then,  that  infec- 
tious diseases,  identical  in  clinical  and  anatomical  appearances  with  the 
various  forms  denominated  septicsemia  in  man,  have  been  induced  in  the 
mouse  and  rabbit  by  inoculation  with  animal  tissues  in  various  stages  of 
putrefaction  ;  that  the  resulting  infection  is  just  as  certain  if  the  putrid 
substances  be  previously  boiled  and  thereby  deprived  of  living  organisms. 
On  the  other  hand,  it  is  certain  that  jjer  ye  innocuous  culture  fluids — infu- 
sions of  beef,  etc. — acquire,  after  inoculation  with  minute  quantities  of  in- 
fected blood  or  tissue,  the  some  septic  properties,  provided  such  blood  or 
tissue  contain  living  bacteria  ;  it  is  further  certain  that  this  multiplication 
of  the  septic  substance  in  such  liquid  is  a  concomitant  of  the  vital  action 
of  the  organisms  therein  contained  ;  it  is  further  demonstrated  that  these 
organisms  can  and  do,  not  alone  multiply  the  septic  material,  but  when 
isolated  by  successive  cultures  from  all  the  accompanying  animal  tissues, 
induce,  independently,  fatal  infectious  diseases.  The  same  principle — 


MICROCOCCUS-POISONING.  51 

•vital  activity  of  bacteria — pervades  all  these  phenomena  ;  for  the  artificial 
induction  of  septic  diseases  has  been,  in  all  these  experiments,  originally 
accomplished  by  the  incorporation  into  the  animal  of  putrid  tissues,  with 
or  without  bacteria.  Now,  since  putrefaction  must  be  regarded,  in  the 
present  state  of  our  knowledge,  as  impossible  without  the  presence  of 
these  organisms,  it  is  evident  that  sepsis,  putrid  infection,  was  in  every 
case  due,  directly  or  indirectly,  to  the  action  of  bacteria  ;  since  even  the 
boiled  substances  used  by  Panum  and  Rosenberger,  and  the  sepsin  ol> 
tained  from  rotten  yeast  by  Bergmann  and  Schmiedeberg,  had  acquired 
their  septic;  properties  through  putrefaction,  Le.,  through  the  action  of 
bacteria.  Hence  we  are  logically  driven,  by  all  this  Avork,  to  the  belief 
that  septicaemia  implies  the  introduction  into  the  animal  either  of  living 
bacteria,  or  of  a  substance  which  has  acquired  noxious  properties  through 
previous  vital  activity  of  these  organisms." 

The  experiments  and  observations  of  Ogston,  to  which  reference  has 
been  made  in  connection  with  inflammatory  disturbances  of  wounds  at- 
tended with  suppuration,  led  that  observer  to  the  conclusion  that  septi- 
caemia, pyieinia,  and  septico-pya>mia  are  one  and  the  same  disease,  and 
that  their  sole  and  invariable  cause  is  micrococcux-poisonwg. 

Pus  containing  micrococci,  obtained  from  an  acute  human  abscess, 
when  injected  by  this  observer  into  the  tissues  of  mice,  in  amounts  of  half 
a  minim  or  more,  produced  symptoms  of  blood-poisoiiing  lasting  from  two 
to  five  days,  during  which  time  micrococci  could  be  detected  in  the  blood 
in  the  heart  ;  the  site  of  the  injection  displayed  a  red  infiltration,  in  which 
appeared  micrococci  invading  the  neighboring  tissues,  penetrating  be- 
tween their  cells,  and  in  colonies  or  chains,  gradually  decreasing  in  size, 
pushing  their  way  for  a  considerable  distance  into  the  structures  in  the 
vicinity.  In  the  centre  of  this  infiltrated  region  would  be  an  abscess. 
The  micrococci  in  the  heart  blood  were  comparatively  few,  and  somewhat 
variable  in  number.  Their  distribution  did  not  appear  to  be  uniform 
throughout  the  blood,  and  their  presence  was  never  detected  in  the  lungs, 
liver,  spleen,  kidneys,  lymphatic  glands,  or  suprarenal  capsules.  After  five 
to  seven  days  had  elapsed,  and  in  some  cases  even  earlier,  the  animals  ex- 
hibited a  change.  They  became  active  again,  threw  off  their  lethargy,  and 
seemed  well ;  but  at  the  spot  where  the  ii:iection  had  been  made,  there 
was  found  a  fluctuating  tumor,  gradually  inc  easing  in  size,  and  present- 
ing all  the  signs  of  being  an  ordinary  abscess.  When  they  were  killed 
during  this  second  stage,  micrococci  were  more  rarely  found  in  the  heart- 


52  THE   TREATMENT    OP    WOUNDS. 

Hood,  and  the  infiltration  of  the  organisms  into  the  tissues  around  the 
abscess  no  longer  existed,  having  been  replaced  by  a  firm  thick  wall  of 
granulation-tissue,  in  which  micrococci  could  seldom  be  detected,  and 
which  seemed  to  act  as  a  barrier,  preventing  or  diminishing  their  mij^ra- 
tion  into  the  blood  and  surrounding  structures.  In  the  viscera  of  animals 
killed  at  this  stage  no  organisms  were  detected.  Some  animals,  however, 
died,  overwhelmed  by  the  blood-poisoning,  at  the  end  of  the  second  or  the 
beginning  of  the  third  day.  In  some  cases  the  local  reaction  was  so  in- 
tense as  to  result,  not  in  abscess,  but  in  sphacelus  of  the  site  of  injection 
and  overlying  skin,  in  which  cases  the  animals  seemed  to  suffer  rather  less 
from  the  symptoms  of  blood-poisoning ;  and,  when  they  were  killed,  few 
micrococci  were  found  in  their  blood,  and  the  necrosed  tissues  were  sur- 
rounded by  a  strong  thick  wall  of  granulation-tissue,  presenting,  at  the 
places  where  the  slough  was  detached,  a  surface  like  that  of  an  ulcer  cov- 
ered with  a  thin,  whitish,  croupy  film,  in  which  the  micrococci  were  grow- 
ing, though  in  a  feeble  and  scattered  manner. 

In  seven  cases  of  septicaemia  in  man,  in  which  he  was  able  to  examine 
the  blood  during  life  by  opening  a  small  arteriole  or  venule,  under  anti- 
septic precautions,  the  blood  so  obtained  was  found  to  contain  micrococci 
in  every  slide  examined. 

In  a  case  of  fatal  septicaemia,  death  occurring  on  the  sixth  day  after  the 
extirpation  of  the  thyroid  gland,  the  wound  teemed  with  micrococci.  In 
a  case  of  septicaemia  following  compound  dislocation  of  the  ankle-joint,  in 
which  death  was  averted  by  amputation,  the  tissues  around  the  margin  of 
the  wound,  and  the  subcutaneous  tissue  far  up  the  leg,  and  the  clots  in 
and  around  the  ankle-joint  were  abundantly  infiltrated  with  micrococci. 
Other  cases  likewise,  he  states,  that  have  come  under  his  observation  tell 
the  same  story.  He  concludes  that  there  is  no  such  disease  as  septicaemia 
or  pyaemia  per  se,  such  conditions  being  merely  secondary  in  the  order  of 
the  morbid  process,  and  dependent  on  the  existence  of  local  foci  of  micro- 
coccus  growth.  For  the  focus  of  the  disease  never  exists  in  the  blood, 
but  always  in  the  tissues,  whence  the  ptomaines  generated  in  micrococcal 
proliferation  pass  into  the  circulation  to  act  as  poisons  or  intoxicants, 
though  separate  individuals  or  small  groups  of  the  micro-organisms  are 
conveyed  by  the  blood  into  other  situations,  so  as  to  reproduce  among 
other  tissues  the  disease  of  the  parent  focus.  In  his  summary  he  uses 
the  following  language  :  "  Phlegmonous  inflammation,  septicaemia,  pya-- 
mia,  and  septico-pysemia  are  all  micrococcus  poisoning,  varied,  however, 


MICROCOCCUS-POISONING.  53 

according  as  ptomaine  intoxication  or  the  local  tissue  reaction  becomes 
more  prominent.  Every  feverishness,  from  an  iuHanied  throat  or  finger, 
is  a  septicaemia  in  a  mild  degree,  and  may  pass  into  a  severe  form.  Pto- 
maines pass  into  the  blood,  and  coincidently  a  few  individuals  of  the  mi- 
crococcus  may  be  found  to  have  wandered  from  the  local  disease  and  to 
be  circulating  in  the  blood,  dead  or  half  dead,  owing  to  the  uusuitabih'ty  of 
the  medium  where  they  are,  and  the  unfavorable  influences  of  the  forces 
of  the  tissues.  If  removed  from  the  blood  they  rarely  grow  when  put  into 
suitable  medium.  They  are  all  eventually  extruded  or  consumed.  But  if 
the  individual  be  subjected  to  depressing  influences,  the  ptomaine  poison- 
ing may  not  be  the  only  phenomenon  observed.  As  the  symptoms  become 
more  severe,  and  the  micrococci  more  numerous  in  the  blood,  the  weak- 
ness of  the  individual  becomes  greater,  and  the  resisting  power  of  his  tis- 
sues less,  so  that  the  micrococci  are  able  to  live  in  the  blood,  where  previ- 
ously they  found  this  impossible.  They  multiply  and  form  small  groups 
that  increase  in  size  until  they  are  too  large  to  pass  through  the  capillary 
net-work,  and  therefore  are  caught  and  detained  in  lungs,  liver,  or  some 
other  part.  There  they  continue  to  increase  during  life,  perhaps  even  for 
a  time  after  death,  and.  furnish  their  contribution  of  poison  to  the  system. 
Or  it  may  be  that,  though  unable  to  multiply  in  the  blood,  they  here  and 
there  throughout  the  body  find  spots  suitable  for  their  development, 
where  they  can  multiply  and  form  the  foci  of  suppuration  that  mark  the 
form  for  which  we  usually  reserve  the  name  pijamda.  The  pyaanic  sec- 
ondary foci  are  usually  in  lung,  or  liver,  or  joint,  but  may  equally  well 
occur  in  lymphatic  glands,  secreting  glands,  or  even  in  connective  tissue." 
In  concluding  the  present  inquiry  into  the  relations  of  micro-organisms 
to  wound-disturbances,  attention  should  be  directed  to  the  results  which 
have  been  obtained  by  methods  of  treatment  that  tend  to  prevent  the 
access  of  such  organisms  to  wounds,  or  to  lessen  their  activity,  if  already 
present.  By  themselves  alone  considered  these  statistical  clinical  data 
would  afford  only  presumptive  evidence  at  best ;  but  when  taken  in  con- 
nection with  the  results  of  the  careful,  minute,  guarded,  experimental  in- 
vestigations which  have  occupied  attention  in  the  preceding  portion  of 
this  chapter,  they  appear  as  the  strongest  kind  of  corroborative  evidence 
of  the  correctness  of  these  results.  Every  wound  treated  in  accordance 
with  the  theoretical  indications  experimentally  demonstrated  becomes  a 
check  upon  the  correctness  of  the  conclusions  deduced  from  the  results 
obtained  by  the  experiment. 


54  THE    TREATMENT    OF    WOUNDS. 

During  the  eighteen  years  which  have  elapsed  since  Joseph  Lister,  in- 
fluenced by  the  results  of  Pasteur's  investigations  into  the  causes  of  putre- 
faction, began  the  use  of  carbolic  acid  as  a  germicide  in  the  treatment  of 
compound  fractures  in  the  Glasgow  Infirmary,  the  theory  that  .noxious 
germs,  conveyed  by  the  atmosphere,  were  the  essential  causes  of  wound- 
disturbances,  has  been  tested  upon  a  vast  scale  by  many  methods  and  by 
a  multitude  of  independent  observers. 

In  the  Glasgow  Infirmary,  at  the  time  Mr.  Lister  began  his  methods  of 
treatment*  based  upon  the  principle  of  antagonizing  germ-activity,  infec- 
tive diseases  were  constantly  present,  and  became  at  times  so  prevalent 
that  the  wards  had  to  be  closed.  Out  of  thirty-five  amputations,  of  all 
kinds,  done  by  him  in  two  years,  sixteen  died,  of  which  deaths  almost  all 
were  due  to  infective  disease — thus  of  the  six  deaths  following  amputa- 
tions of  the  upper  extremity,  four  were  due  to  pyjtmia  and  one  to  hospital 
gangrene.  After  the  adoption  of  his  new  methods,  though  they  were 
as  yet  crude,  during  three  years,  there  were  but  two  deaths  from  py- 
jeniia  after  amputation,  out  of  forty  amputations  performed,  and  in  one  of 
these  the  pya-mia  existed  prior  to  the  operation.  These  were  the  only 
cases  of  pyteniia  which  occurred  in  Mr.  Lister's  hospital  practice  during 
these  three  years,  though  there  were  twenty-two  compound  fractures  and 
several  compound  dislocations  treated  during  this  time.  One  case  of  ery- 
sipelas, and  one  or  two  cases  of  hospital  gangrene,  of  a  mild  type,  com- 
plete the  list  of  infective  diseases  that  occurred  during  this  time.  The 
results  of  Mr.  Lister's  work  in  the  Royal  Infirmary,  of  Edinburgh,  and  in 
King's  College  Hospital,  of  London,  from  1871  to  1880,  were  of  the  same 
character.  They  will  be  found  reported  at  length  in  Cheyne's  work  on 
antiseptic  surgery,  which  is  the  source  of  the  facts  already  given,  and 
of  the  following  statements  as  to  results  obtained  by  Volkinann  and 
Nussbaum. 

In  1877  Professor  Volkmann,  of  Halle,  reported  that  not  a  single  case  of 
pyiemia  or  septicaemia  had  occurred  among  patients  treated  by  him  asepti- 
cally  during  three  years,  notwithstanding  the  deaths  from  pyaemia  and 
septicaemia  had  been  so  numerous  previous  to  the  adoption  of  this  par- 
ticular method  of  treatment  that  the  entire  closing  of  the  hospital  for  a 
time  seemed  necessary. 

In  1878  Professor  Nussbaum,  of  Munich,  tabulated  the  results  of  the 
treatment  of  wounds,  in  the  General  Hospital  under  his  care,  before  and 
after  the  adoption  of  aseptic  methods,  thus  : 


RESULTS    OF   ANTISEPTIC   TREATMENT.  55 

Formerly.  N&w. 

"  Injuries  of  the  head,  compound  fractures,  No  pyaemia, 

amputations  and  excisions,  in  fact,  almost  all  pa- 
tients in  whom  bones  were  injured  were  attacked 
by  pyaemia.  For  example,  of  seventeen  cases  of 
amputation,  eleven  died  from  this  cause.  Even 
patients  with  severe  whitlow  died  of  it. 

"  Hospital  gangrene  had  got  the  upper  hand  No  hospital  gangrene, 
to  such  an  extent,  that  in  spite  of  continuous  water 
baths,  in  spite  of  the  use  of  chlorine  water,  or  the 
actual  cautery,  finally  eighty  per  cent,  of  all 
wounds  and  ulcers  were  attacked,  large  arteries 
being  opened  into. 

"  Almost    every-    wound    was    attacked    with  Xo  erysipelas." 

erysipelas. 

In  summing  up  five  years'  experience,  in  the  last  edition  of  his  work  on 
antiseptic  surgery,  published  in  1880,  he  goes  so  far  as  to  say  that  "  any 
recent  wound,  treated  by  this  method  is  guaranteed  against  pyaemia,  hos- 
pital gangrene,  erysipelas,  progressive  suppuration,  and  in  general  against 
all  accidental  complications." 

Schede,  in  the  fasciculus  011  amputations  and  resections  in  Pitlia  and 
Billroth's  "Handbuch,"  giA-es  comparative  tables  of  321  uncomplicated 
amputations  performed  aseptically,  and  of  377  treated  by  older  methods. 
The  first  were  under  the  care  of  Busch,  Schede,  Sorin,  and  Volkmann. 
The  latter  were  furnished  by  Brans,  Bardeleben,  and  Billroth.  Of  the 
aseptic  cases  14  died,  or  4.4  per  cent.  ;  of  the  ordinary  cases  110  died,  or 
29.18  per  cent,  The  causes  of  death  were  tabulated  as  follows  : 

Septic  cases.      Aseptic  cases. 

Pyaemia 72  0 

Septicaemia 

Eiy  sipelas 

Trismus 0 

Pyaemia  simplex <> 

Haemorrhage 

Exhaustion 

Shock (> 

110  14 


56  THE    TREATMENT    OF    WOUNDS. 

William  Macewen,  of  Glasgow,  in  his  work  on  Osteotomy,  published 
in  1880,  reports  835  osteotomies  of  the  femur,  tibia,  and  fibula,  which 
were  compound  osseous  incisions  or  fractures  treated  antiseptically.  In 
many  of  the  patients  the  general  health  was  far  from  being  satisfactory, 
and  was  such  as  would  have  precluded  most  operations.  The  majority 
were  in  a  low  state  of  health;  a  number  were  markedly  tubercular. 
There  were  many,  however,  who  were  in  good  general  health.  With  the 
exception  of  eight  cases,  all  the  wounds  healed  by  organization  of  blood- 
clot  without  pus-production.  Of  the  eight  which  suppurated  there  were 
recognizable  traumatic  causes  for  the  suppuration  in  seven.  In  one  only 
was  there  no  clear  reason  to  be  assigned  for  the  pus-production.  All  ulti- 
mately did  well,  with  one  exception,  in  which  case  amputation  was  finally 
necessitated. 

Professor  H.  B.  Sands,  of  New  York,  in  the  New  York  Medical  Journal, 
of  January  6,  1883,  declares  that  in  his  own  experience  a  wonderful  im- 
provement has  been  wrought  in  the  management  of  wounds  by  antiseptic 
surgery.  Primary  union  is  now  the  rule  where  formerly  it  was  the  excep- 
tion ;  diffuse  inflammation  and  suppuration  are  rare  even  after  severe  inju- 
ries ;  operations  once  formidable  now  excite  little  apprehension  ;  and  that 
dreadful  scourge,  pyaemia,  has  been  nearly  abolished.  In  the  surgical  ser- 
vice of  the  Koosevelt  Hospital,  containing  seventy-five  beds,  no  operation 
performed  during  the  last  three  years  has  been  followed  by  septicaemia  or 
pyaemia. 

Professor  William  Stokes,  of  Ireland,  in  the  "  Address  in  Surgery,"  be- 
fore the  British  Medical  Association  in  1882,  claims  that  one  of  the  best 
tests,  if  not  the  best,  for  the  value  of  antiseptic  practice,  is  resection  of  the 
knee-joint,  as  there  are  so  many  circumstances  that  militate  against  imme- 
diate union  being  obtained  after  it.  In  the  first  place,  as  he  says,  the 
cases  requiring  so  formidable  an  operation,  are,  as  a  rule,  in  a  condition  of 
great  physical  exhaustion,  consequent  on  long  confinement,  and  probably 
protracted  suffering  of  mind  and  body.  The  wound  is  of  necessity  a  large 
one ;  the  operation  occupies  a  considerable  time  ;  two  large  freshly  cut 
bone  surfaces  are  made,  between  which  union  is  to  take  place ;  and,  lastly, 
there  is  the  great  difficulty  of  keeping,  no  matter  what  appliance  be 
adopted,  the  limb  absolutely  at  rest  during  the  process  of  union.  Before 
the  adoption  of  Listerism  the  surgeon  anticipated  that  four,  six,  or  eight 
months,  or  longer,  would  elapse  before  union  took  place,  and  it  was  always - 
a  subject  discussed  at  consultations  on  these  cases,  previously  to  operation, 


STOKES LISTER LITTLE.  57 

whether  the  patient  would  have  strength  to  endure  so  protracted  a  suppu- 
ration. As  an  illustration  of  how  changed  matters  are  now,  he  quotes 
a  series  of  fourteen  cases  of  excision  of  the  knee-joint,  in  nine  of  which 
the  wounds  united  without  a  trace  of  pus-production  ;  and  in  another, 
the  last  of  the  series,  only  two  dressings  were  required  subsequent  to  the 
one  applied  at  the  time  of  the  operation,  and  in  seven  weeks  after  the  pa- 
tient was  up  and  going  about.  He  further  states  that  in  a  record  of  up- 
ward of  six  hundred  operations  performed  by  himself  and  his  colleagues 
at  the  Kichmond  Surgical  Hospital  during  the  previous  three  years,  an  in- 
stitution which  was  hygienically  in  a  very  unsatisfactory  condition,  the 
mortality  was  3.6  per  cent.;  there  was  not  a  single  case  in  which  the 
methods  of  Lister  were  accurately  employed  that  was  foUowed  by  any  in- 
fective disease. 

With  regard  to  the  course  of  repair  in  the  wound-site  itself,  Cheyne 
testifies  that  where  wounds  have  been  treated  in  accordance  with  the 
aseptic  methods  of  Mr.  Lister  no  inflammation  occurs ;  there  is  no  swell- 
ing nor  redness  of  the  edges,  as  is  so  frequently  the  case  in  wounds 
treated  otherwise.  The  skin  around  the  wound  remains  as  pale  and  lax 
as  it  was  when  stitched  up  at  the  time  of  the  operation  ;  there  is  no  evi- 
dence of  reaction  ;  inflammation  is  absent  from  the  deeper  as  well  as  from 
the  superficial  parts  of  the  wound.  There  is  no  suppuration  even  when  the 
deeper  structures  are  not  absolutely  in  contact.  The  discharge  from  the 
drainage-tube  is  purely  serous,  and  rapidly  diminishes  in  amount  so  as  to 
render  the  drain  unnecessary  in  a  very  short  time.  Wounds  heal,  as  a 
rule,  much  more  rapidly  than  when  treated  otherwise  ;  as  a  result  of  the 
absence  of  inflammation  in  the  deeper  parts,  the  scar  does  not  become  ad- 
herent but  remains  movable. 

Of  the  same  character  is  the  testimony  of  Professor  James  L.  Little,  of 
New  York,  in  remarks  made  by  him  before  the  New  York  Surgical  Soci- 
ety, November  8,  1881,  in  which  he  said  that  during  a  period  of  six  years 
he  had  treated  nearly  three  hundred  cases  of  open  wounds,  these  injuries 
consisting  chiefly  of  wounds  of  the  hands  and  fingers  caused  by  their 
being  caught  in  the  cogwheels  and  other  parts  of  machinery.  In  many 
cases  fingers  were  torn  off,  tendons  puUed  from  their  sheaths,  joints 
opened,  and  hands  often  severely  crushed  and  lacerated.  Many  of  these 
patients  were  in  an  unhealthy  condition,  some  suffering  from  anaemia, 
some  from  cardiac  disease,  phthisis,  and  the  like.  Under  antiseptic  dress- 
ings, not  one  of  these  wounds  was  followed  by  inflammatory  symptoms. 


58  THE    TREATMENT    OF    WOUNDS. 

Extensive  lacerated  wounds  healed,  and  dead  tissue  sloughed  away  with- 
out giving  rise  to  any  of  the  so-called  symptoms  of  inflammation.  Neither 
pain,  redness,  heat,  swelling,  nor  constitutional  disturbance  resulted.  In 
no  case  was  there  reddening  of  the  lymphatics  or  tenderness  of  the  glands. 
No  counter-openings  were  necessary.  Pain  was  entirely  absent,  so  that 
anodynes  were  not  needed,  save  in  a  single  case,  and  that  for  one  night 
only,  to  control  slight  restlessness. 

Citations  of  a  similar  character  to  the  preceding  could  be  made  from 
the  testimonies  of  an  indefinite  number  of  surgeons  on  both  sides  of  the 
Atlantic.  They  are  alike  in  their  statements  that,  in  proportion  as  it  has 
been  possible  for  them  to  perfect  methods  of  wound  treatment  by  which 
the  development  of  micro-organisms  could  be  prevented  or  diminished, 
disturbances  of  repair  have  been  escaped  and  healing  has  been  safe  and 
speedy  and  perfect. 

In  bringing  this  chapter  to  a  close,  there  confronts  us  the  question, 
"What  conclusion  as  to  the  relation  of  micro-organisms  to  wound-dis- 
turbances is  most  consistent  with  all  the  facts  which  have  thus  far  been 
established  ?  Three  great  groups  of  phenomena  present  themselves  from 
which  to  draw  pertinent  observations,  viz.  :  1,  the  behavior  of  wounds 
which  were  exposed  to  the  access  of  micro-organisms  or  their  germs,  and 
which  presented  conditions  favorable  for  their  vital  activity ;  2,  experi- 
mental research  as  to  the  nature  and  the  effects  produced  by  the  different 
species  of  micro-organisms  ;  and,  3,  the  effects  tipon  the  course  of  healing  in 
wounds  produced  by  protecting  them  from  germ  invasion  or  by  destroying 
or  diminishing  the  activity  of  such  as  may  have  gained  access  to  them. 

In  the  first  class  are  all  open  wounds,  in  which  the  conditions  favor- 
able for  the  development  of  activity  of  germs  sown  upon  them  become  the 
more  pronounced  in  proportion  as  the  amount  of  devitalized  tissue,  and  of 
blood-clot,  and  the  number  and  depth  of  recesses  for  the  reception  and 
retention  of  wound-secretions  increase. 

Observation  of  this  class  records  that  invariably  their  repair  is  dis- 
turbed by  putrefaction  and  sloughing  of  the  devitalized  tissues,  by  decom- 
position and  liquefaction  of  the  blood-clots,  by  inflammation  of  the  wound- 
margins,  and  by  a  prolonged  process  of  suppuration  and  granulation,  and, 
in  a  certain  number  of  cases,  by  grave  septicaemia,  and  by  pyaemia. 

In  the  second  class  stand  out  the  facts  that  no  decomposition  or  fer- 
mentation takes  place  in  organic  matter  without  the  agency  of  some  form 
of  micro-organism;  that  when  no  decomposition  of  wound-tissues  or 


IMMUNITY    FEOM    \VOUND-DISTUKBANCES.  59 

secretions  takes  place  no  wound-disturbance  occurs ;  that  certain  forms  of 
micro-organisms  are  always  found  associated  with  certain  forms  of  wound- 
disturbance  ;  and  finally,  that  these  micro-organisms,  when  isolated  and 
introduced  anew  in  sufficient  amount  among  tissues  previously  healthy, 
are  capable  of  exciting  here  the  same  diseased  action  with  which  they  were 
originally  found  associated. 

In  the  third  class  are  subcutaneous  wounds,  in  wiiich  the  unbroken 
skin  forms  a  perfect  shield  against  the  invasion  of  noxious  organisms  from 
without ;  wounds  involving  the  integument,  in  which  apposition  of  the 
divided  surfaces  can  be  secured  and  maintained,  and  the  retention  of 
wound-secretions  prevented,  and  in  which  the  inherent  force  of  the  con- 
structive powrer  of  the  healing  tissues  is  great  enough  to  destroy  whatever 
germs  may  gain  access  while  the  surfaces  are  exposed ;  and  wounds  of 
every  class  in  the  treatment  of  which  adequate  measures  have  been  used  to 
prevent  the  access  of  genus,  or  to  destroy  them,  or  prevent  their  develop- 
ment if  present. 

Clinical  observation  records,  for  all  the  members  of  this  third  class  in 
which  protection  from  invasion  of  micro-organisms  is  secured  in  various 
ways,  a  common  immunity  from  wound-disturbances.  The  repair  of  sub- 
cutaneous wounds  is,  as  a  rule,  free  from,  suppuration,  inflammation,  and 
sloughing,  or  other  serious  complication,  even  though  involving  much 
contusion  and  laceration  of  soft  parts  and  extensive  effusion  of  blood. 
Union  by  first  intention,  without  disturbance,  accident,  or  delay,  is  the 
rule  when  the  conditions  next  mentioned  are  obtained  ;  and,  in  like  man- 
ner, a  course  of  repair  free  from  disturbance  and  closely  approximating 
in  rapidity  and  perfection  that  of  subcutaneous  wounds  is  enjoyed  by  the 
last-mentioned  wounds.  The  evidence  which  each  of  these  groups  of 
phenomena  gives  is  harmonious  and  cumulative,  and  the  only  conclusion 
which  is  consistent  with  them  is  that  the  local  suppurative  and  inflamma- 
tory, and  the  general  infective  disturbances  which  occur  in  wounds  result 
from  the  vital  activity  of  micro-organisms,  which  having  been  introduced 
from  without,  find  in  the  wound  the  conditions  that  favor  their  develop- 
ment and  increase. 

Other  sources  of  irritation  likewise  exist  and  are  capable  of  exciting 
suppuration  and  inflammation  in  wounds,  but  their  effects  are  limited  and 
transient  in  character,  their  action  is  easily  recognizable  and  preventable, 
and  their  chief  importance  springs  from  the  manner  in  which  the  con- 
ditions created  by  them  favor  the  activity  of  micro-organisms. 


CHAPTER  IV. 
ASEPSIS  AND  ANTISEPSIS— WOUND-CLEANLINESS. 

The  Scientific  Basis  of  Wound-Treatment — Ptomaines — Sepsis — Asepsis — Antisepsis — 
Cleanliness — Primary  Cleansing  of  a  Wound — Drainage — Cleanliness  of  Adjacent 
Tissues — Cleanliness  of  Wound-Dressings — Air  Purification — Antiseptic  Sprays — 
Practice  of  Lister — Experiments  of  Stimson  and  Duncan — Effects  of  Sprays.  , 

THE  recognition  of  the  activity  of  micro-organisms  as  the  essential  cause 
of  disturbances  of  repair  in  wounds  supplies  a  scientific  basis  for  treat- 
ment and  affords  a  definite  principle  by  which  to  test  methods  of  wound- 
treatment.  It  has  been  seen  that  it  is  not  the  organisms  themselves 
that  are  the  irritants  that  directly  cause  wound-disturbance,  but  the  pro- 
ducts that  are  formed  in  the  course  of  their  growth  and  multiplication, 
either  directly  secreted  by  themselves  or  formed  by  the  decomposition 
of  the  substances  on  which  they  feed.  These  secondaiy  products — 
ptomaines — are  poisons  or  septic  agents,  and  the  results  in  general  of 
their  action  upon  the  living  tissues  with  which  they  come  in  contact 
constitute  sepsis.  Whatever  tissue  or  wound-surface  is  uncontaminated 
by  these  ptomaines  is  in  an  aseptic  condition,  and  whatever  method  or 
means  antagonizes  their  production,  or  antidotes,  restricts,  or  removes  the 
results  of  their  presence  is  an  antiseptic. 

The  ideal  treatment  of  a  wound  is  that  by  which  a  perfectly  aseptic 
condition  should  be  obtained  and  preserved  ;  where  this  is  impracticable, 
the  object  of  treatment  becomes  changed  to  the  application  of  means  to 
diminish  the  activity  of  the  septic  organisms,  to  secure  the  rapid  removal 
of  their  products,  and  to  increase  the  resisting  power  of  the  wounded 
tissues. 

ASEPSIS. 

Asepsis  is  present  in  wounds  which  are  subcutaneous,  and  in  wounds 
which  unite  by  first  intention.  The  defects  of  apposition,  protection,  or 
nutrition  which  may  prevent  the  accomplishment  of  union  by  first  inten- 


ASEPSIS    AND    ANTISEPSIS.  61 

tion  in  a  wound  do  not  necessarily  expose  it  to  septic  infection,  but  so 
much  do  they  increase  the  difficulties  of  preserving  the  wound  from 
such  infection  that  the  means  of  remedying  these  defects,  and  of  securing 
union  by  first  intention,  when  the  conditions  of  the  wound  make  it  at  all 
possible,  become  of  the  highest  importance  from  the  standpoint  of  the 
dangers  of  sepsis.  The  methods  by  which  these  defects  are  to  be  avoided 
belong  to  the  practice  of  wound-treatment  and  will  be  reserved  for  con- 
sideration in  that  connection.  Attention  here  must  be  restricted  to 
general  considerations  bearing  directly  upon  the  prevention  or  correction 
of  sepsis. 

Asepsis  may  be  preserved,  if  the  wound  is  to  be  inflicted  by  the  sur- 
geon himself,  by  care  in  permitting  access  to  the  wound,  at  the  time  of  its 
infliction  and  during  its  after  progress,  of  no  object  which  is  contaminated 
by  septic  agents.  This  involves  purification  of  the  air,  instruments,  dress- 
ings, and  of  the  hands  of  the  surgeon  himself,  and  the  most  minute, 
exact,  and  persistent  care  throughout  the  course  of  the  wound  until  its 
final  cicatrization. 

In  wounds  already  septic,  asepsis  may  be  obtained  by  applying  to 
their  surfaces  and  recesses  substances  capable  of  destroying  the  septic 
germs  and  organisms  present,  and  by  using  in  their  after-care  dressings 
capable  of  excluding  the  further  access  of  septic  agents,  or  of  preventing 
their  development  if  their  exclusion  has  been  impossible. 

ANTISEPSIS. 

In  wounds  in  which,  for  any  reason— their  location,  their  complica- 
tions, the  absence  of  necessary  appliances,  or  whatever  other  cause- 
asepsis  is  impossible  or  impracticable,  the  effects  of  the  septic  agents  that 
may  be  present  may  be  modified  and  restrained,  not  only  by  the  appli- 
cation' to  the  wounds,  as  thoroughly  as  possible,  of  antiseptic  substances, 
but  also  by  the  most  perfect  removal  from  the  wound  of  devitalized 
substances  and  those  prone  to  decomposition,  which  if  left  would  bo 
rich  feeding-ground  for  micro-organisms,  by  the  immediate  removal  of 
the  noxious  products  of  the  septic  condition  as  fast  as  produced,  and  by 
whatever  agencies  are  capable  of  promoting  general  reparative  energy  or 
local  resisting  power  in  the  wound-tissues. 

The  range  covered  by  this  enumeration  of  the  means  and  methods  of 
antagonizing  septic  conditions  in  wounds— antisepsis— is  a  wide  one,  and 


62  THE   TREATMENT    OF    WOUNDS. 

includes  every  form  of  wound-treatment  which  by  experience  has  been 
found  to  favorably  affect  the  healing  of  wounds.  Those  methods  only, 
however,  which  in  a  special  manner  modify  the  vital  activity  of  noxious 
micro-organisms,  or  nullify  the  results  of  such  activity,  can  be  considered 
in  this  connection.  These  methods  will  be  considered  in  the  following 
order : 

First. — Those  that  are  required  to  prevent  the  accumulation,  or  to  en- 
sure the  removal  of  whatever  substances  might  afford  a  pabulum  favorable 
to  the  growth  and  increase  of  septic  organisms  ;  to  facilitate  the  removal 
of  septic  products,  if  formed ;  and  to  prevent  the  introduction  into  the 
wound  of  any  substance  capable  of  inducing  septic  changes  in  it ;  these 
methods  are  embraced  in  the  single  idea,  cleanliness. 

Second. — The  employment  of  substances  as  appli cations  to  wound-sur- 
faces which  are  inimical  to  septic  organisms,  destroying  them  or  restrain- 
ing their  growth — antiseptics,  in  the  more  restricted  sense  of  the  term. 

CLEANLINESS. 

That  aspect  of  cleanliness  which  has  to  do  with  the  prevention  of  the 
accumulation,  and  with  the  speedy  removal  of  fermentable  substances  from 
a  wound  requires  for  its  accomplishment,  at  the  beginning  of  treatment, 
the  removal  of  every  substance  which  either  itself  should  foster  the  growth 
of  micro-organisms,  or  should  provoke  undue  secretion  from  the  wound, 
or  that  by  the  mechanical  effect  of  its  presence  should  delay  union.  The 
accomplishment  of  this  end  constitutes  primary  cleansing  of  the  icound. 
The  full  performance  of  tliis  cleansing  may,  however,  involve  such  increased 
hazards  from  the  additional  traurnatisni  required  for  its  accomplishment 
in  some  instances,  that  it  may  best  be  ignored,  as  in  cases  of  bullets, 
needles,  and  other  bodies  that  have  penetrated  the  tissues,  and,  becoming 
encysted,  cease  to  irritate,  and  disturb  but  little  the  function  of  the  parts 
in  which  they  rest  Again,  in  cases  in  which  an  accumulated  blood-clot 
would  appeal-  to  violate  the  rule  of  cleanliness  by  its  proneness  to  decom- 
position and  by  the  mechanical  effects  of  its  presence,  if  it  can  be  kept 
aseptic,  or  if  efficient  means  of  antisepsis  be  available,  it  may,  in  cases  of 
open  wounds,  with  loss  of  substance  so  great  as  to  prevent  apposition  of 
the  divided  surfaces,  really  facilitate  repair  by  affording  pabulum,  sup- 
port, and  protection  to  the  forming  granulation-t issue  that  gradually  takes 
its  place.  In  cases,  also,  in  which  rapid  drying  of  a  layer  of  blood-clot 


CLEANLINESS DRAINAGE.  63 

can  be  accomplished,  the  impermeable  layer  which  it  forms  may  consti- 
tute a  perfect  occlusive  antiseptic  dressing  for  the  wound  underneath  it ; 
but  the  doing  up  of  a  wound  "in  its  own  blood,"  to  be  successful,  requires 
that  the  other  possible  demands  of  cleanliness  that  may  be  present  or  may 
arise  in  the  wound  be  also  regarded. 

Of  equal  importance  with  the  primary  cleansing  of  the  wound  is  the 
prevention  of  the  accumulation  within  its  cavity  at  any  time  in  its  after- 
history  of  wound-secretions  and  tissue-debris.  The  abundant  serous  ex- 
udation which  occurs  as  the  immediate  result  of  the  active  hypereemia 
provoked  by  a  wound,  bathes  in  abundance  the  free  surfaces  of  an  open 
wound  and  gathers  in  its  recesses,  and  when  such  wounds  are  closed  ex- 
ternally, if  exact  apposition  of  its  deeper  parts  be  not  also  secured  and 
maintained,  separates  its  surfaces,  and  as  long  as  it  is  retained,  not  only 
disturbs  repair  by  the  tension  produced,  but  also  offers  the  best  of  pabu- 
lum for  promoting  the  vital  activity  of  ferment-producing  organisms.  The 
prevention  of  such  accumulation  and  retention  becomes,  therefore,  of  the 
highest  importance  in  attempts  to  preserve  a  wound  from  disturbance. 

Again,  when  suppuration  has  occurred  in  a  wound,  the  pus  brings  into 
the  wound  the  same  elements  of  danger  which  attend  the  earlier  serous 
exudation,  with  the  added  condition  that  septic  products  are  already  being 
mingled  with  the  wound-secretions. 

The  spontaneous  escape  and  draining  away  of  all  secretions  and  tissue- 
debris,  as  fast  as  exuded  or  separated,  may  be  provided  for  either  by  the 
special  arrangement  of  the  wound-surfaces  alone,  or  by  the  use  of  appara- 
tus to  drain  them  away.  This  portion  of  the  requirements  for  securing 
cleanliness  in  wounds  is  termed  drainage. 

To  so  manage  a  wound  as  to  prevent  or  to  restrain  the  primary  serous 
effusion  will  diminish  the  necessity  for  provisions  for  drainage.  This  can 
be  accomplished  in  great  measure  in  all  wounds  in -which  such  apposition 
of  the  surfaces  can  be  secured  as  to  make  union  by  first  intention  possible. 
This  should  be  the  ideal  to  be  striven  for  in  all  such  cases.  Its  accom- 
plishment means  careful  and  perfect  ha-mostasis,  careful  primary  cleans- 
ing, careful  expression  from  the  wound-cavities  as  its  surfaces  are  being 
brought  into  apposition  of  all  fluids  present,  perfect  coaptatiou  throughout, 
all  parts  of  the  wound,  deep  and  superficial,  gentle  compression,  and  sup- 
port and  perfect  protection,  with  infrequent  dressings  thereafter.  With 
the  perfect  accomplishment  of  such  precautions  no  accumulation  of  serum 
is  possible,  and  provisions  for  drainage  are  unnecessary  and  objectionable. 


64  THE   TREATMENT   OF   WOUNDS. 

But  whenever  accurate  coaptation  is  not  secured,  and  a  cavity  exists  in 
which  fluid  may  accumulate,  its  drainage  must  be  provided  for. 

The  last  requirement  of  wound-cleanliness,  according  to  our  analysis, 
is  the  prevention  of  access  to  the  wound  of  any  substance  capable  of  in- 
ducing septic  changes  in  it  From  their  relation  to  this  requirement  must 
be  considered :  1,  Cleanliness  of  adjacent  tissues ;  2,  cleanliness  of  wound- 
dressings  ;  and  3,  cleanliness  of  the  air  that  comes  in  contact  with  the  wound. 

ADJACENT  TISSUES. — Perfect  cleanliness  requires  not  only  that  the  tis- 
sues immediately  adjacent  to  a  wound  be  purified  of  gross  impurities,  but 
that  they  should  especially  be  freed  from  any  micro-organisms  which 
might,  by  gaining  access  to  the  wound,  make  it  septic. 

Examination  of  the  skin  on  regions  much  subjected  to  frictions  and 
ablutions,  as  the  hands,  fronts  of  the  thighs,  arms,  and  forearms,  shows 
micro-organisms  so  sparingly  that  epidermis  removed  from  thence  by 
scraping  may  often  exhibit  few  or  none.  But  in  individuals  who,  from 
any  cause,  do  not  practise  frequent  ablutions,  even  in  these  regions  they 
are  usually  found,  while  in  not  even  the  most  cleanly  person  does  the  in- 
terdigital  scurf  of  the  toes  fail  to  show  abundance  of  both  micrococci  and 
bacteria.  The  scurf  of  the  scalp  contains  mostly  fungi  and  fungus  spores, 
and  is  by  no  means  rich  in  cocci  or  bacteria,  while  the  secretion  of  the 
umbilicus  shows  both  these  forms  to  be  present  in  abundance. 

Micrococci  are  numerous  in  the  cerumen  of  the  ears  and  in  the  mucus 
on  the  lips,  and  there  exceed  in  number  the  other  forms  of  organisms.  In 
the  axilla,  on  the  other  hand,  where  micro-organisms  are  in  great  plenty, 
the  bacteria  preponderate,  and  in  the  secretion  from  the  skin  of  the  nose, 
that  is  mostly  sebaceous,  obtained  by  gently  compressing  its  tip,  almost 
the  only  forms  met  with  are  the  bacteria,  which  are  there,  however,  innu- 
merable. 

Sebum  expressed  from  scrota!  or  perinea!  follicles  shows  multitudinous 
bacteria,  slender  rods,  and  micrococci ;  the  anal  region  shows  thick  and 
slender  bacilli,  bacteria,  and  micrococci ;  while  the  faeces  and  interior  of 
the  bowels  present  the  appearance  of  being  entirely  composed  of  infinite 
colonies  of  all  varieties. 

The  author '  on  whose  authority  these  statements  are  made  adds : 

"We  need  not  even  call  into  account  the  solids,  fluids,  and  gases. 
around"  us  in  our  search  for  sources  of  infection  when  we  possess  in  our 

1  Dr.  Alex.  Ogston  :  Micrococcus  Poisoning.  Journal  of  Anatomy  and  Physiology, 
Vol.  XVI.,  p.  557. 


DISINFECTION    OF   THE    SKIN.  65 

own  frames  so  abundant  a  supply.  In  relation  to  surgical  questions,  it  is 
of  use  to  know  the  extent  and  distribution  of  these  germs  on  our  persons, 
if  our  processes  of  disinfection  are  to  be  conducted  aright.  In  operative 
procedures  on  the  axilla  and  scrotum,  for  example,  we  ought  to  know  that 
all  our  preliminary  washings  and  disinfection  are  impotent  to  extermi- 
nate the  micro-organisms  that  exist  in  the  openings  of  the  glands  to  a 
depth  of  one-fourth  of  an  inch  and  even  more.  None  of  the  proceedings 
in  use  in  antiseptic  surgery  is  of  any  avail  to  destroy  them  ;  they  will 
continue  to  grow  and  reach  the  surface,  and  unless  we  maintain  there  a 
storehouse  of  some  disinfectant  material,  frequently  renewed,  that  will 
suffice  to  saturate  all  discharges  and  convert  them  into  aseptic  fluids,  we 
shall  assuredly  find  the  organisms  growing  richly  under  our  dressings, 
lodoform  and  salicylic  acid,  which  are  treasure-houses  of  disinfection,  are 
more  useful  in  those  regions  than  on  the  arms,  legs,  and  hands.  But  even 
in  these  purer  territories  over-confidence  is  perilous,  and  where  we  are 
dealing  with  skins  not  regularly  cleaned,  as  is  the  case,  for  instance,  to  a 
large  extent  in  hospital  practice,  we  have  to  add  to  our  habitual  precau- 
tions, and  attend  both  to  preliminary  saturation  of  the  epidermis  with 
penetrating  disinfectants  and  to  the  subsequent  maintenance  of  stores  of 
disinfectants  on  the  surfaces  where  the  germs  may  develop  and  appear. 
For  a  considerable  time  back  I  have  found  it  advantageous,  in  any  opera- 
tion that  involved  serious  danger,  and  that  required  to  be  successful  at  all 
hazards  (operations  of  complaisance,  such  as  osteotomies  and  joint  opera- 
tions), to  dress  the  part  for  days  before  operation  in  a  regular  Lister's 
dressing,  renewing  it  daily,  and  saturating  the  skin  with  carbolic  water, 
besides  washing  the  part  with  turpentine  immediately  before  making  the 
first  incision;  I  do  not  think  I  am  wrong  in  saying  that  we  are  too  easily 
satisfied  with  our  cutaneous  disinfection,  and  that  the  chief  source  of 
micro-organisms  in  wounds  is  from  the  skin,  rather  than  from  the  air  or 
failures  in  our  antiseptic  procedures." 

The  difficulty  of  securing  the  desired  purification  of  the  adjacent  tissues 
becomes  almost  insuperable  in  wounds  involving  the  mucous  orifices  of 
the  body,  so  that  unless  they  are  of  such  a  character  that  perfect  apposi- 
tion of  the  wound  surfaces  can  be  secured,  and  immediate  union  by  first 
intention  obtained,  they  inevitably  become  septic  wounds.  Such  wounds, 
therefore,  cannot  be  treated  by  occlusive  methods  ;  efforts  must  be  directed 
to  antagonizing  the  inevitable  sepsis  and  removing  its  products.  But  in 
all  wounds,  whether  operative  wounds  at  the  hands  of  the  surgeon  or 
5 


66  THE  TREATMENT   OF   WOUNDS. 

wounds  accidentally  inflicted,  in  which  attempts  at  rendering  and  keeping 
them  aseptic  offer  any  hopes  of  success,  all  such  attempts  must  include 
the  purification  of  that  portion  of  the  skin  which,  is  covered  in  by  the  dress- 
ings, as  much  as  the  wound-surfaces  themselves.  Too  great  care  in 
cleansing  it  cannot  be  taken. 

WOUND-DRESSINGS. — In  this  class  are  to  be  included  everything  which 
necessarily  is  brought  in  contact  with  the  wound  in  the  attentions  which 
it  requires,  as  well  as  those  substances  which  are  applied  more  or  less 
permanently  to  the  wound  to  promote  its  healing.  The  persons  of  the 
surgeon  and  his  assistants,  the  instruments  and  appliances  of  every  kind 
that  are  used  in  or  about  the  wound,  the  fluids  that  are  used  for  irrigation, 
the  drains,  the  ligatures,  the  sutures,  the  compresses,  and  protective  ap- 
pliances, must  each  equally  comply  with  that  degree  of  cleanliness  which 
shall  be  necessary  to  prevent  them  from  becoming  the  bearers  of  infection. 

AIR    PURIFICATION. 

The  more  obvious  sources  of  atmospheric  impurity  are  overcrowding, 
deficient  ventilation,  the  presence  of  unhealthy  suppurating  wounds,  the 
presence  of  infectious  diseases,  the  proximity  of  walls,  beds,  or  other  ab- 
sorbent materials  charged  with  septic  emanations,  the  vicinity  of  cess- 
pools, sewer-basins,  masses  of  putrefying  material,  or  other  foci  of 
infection.  The  mention  of  these  is  sufficient  to  suggest  the  means  of 
remedying  them.  No  one  of  them  should  be  overlooked  in  considering 
the  cares  to  be  rendered  a  wound.  To  the  results  which  attend  their 
neglect,  attention  has  been  called  in  a  previous  chapter. 

The  air  of  the  country  is  more  free  from  micro-organisms  than  is  the 
air  of  a  city,  and  that  of  the  upper  floor  of  a  house  than  that  of  the  lower 
floor.  Facts  that  should  be  borne  in  mind  when  a  choice  as  to  where  a 
wounded  person  should  be  treated  is  possible.  After  every  ordinary  pre- 
caution possible  has  been  taken  to  secure  a  pure  atmosphere  by  clean  and 
pure  surroundings,  isolation,  and  abundant  ventilation,  what  further  means 
are  necessary  and  available  for  securing  absolute  air-purity  ? 

As  has  been  stated  in  a  previous  chapter,  putrescence  invariably  follows 
a  sufficient  exposure  of  putrescible  fluid  to  the  air,  the  length  of  the 
exposure  needed  being  dependent  upon  the  character  of  the  local  sur- 
roundings. Dr.  Duncan,  of  Edinburgh,1  found  that  in  his  laboratory  a 


1    Germs  and  the  Spray.     Edinburgh  Medical  Journal  March,  1883,  p.  778. 


ANTISEPTIC    SPRAYS.  67 

fluid  presenting  a  surface  of  an  inch  and  a  quarter,  could  be  repeatedly 
exposed  for  nearly  two  hours  without  infection,  and  that  to  be  reasonably 
certain  of  putrescence  a  surface  of  three  inches  and  a  quarter  required  an 
exposure  of  twenty  minutes.  The  volumes  of  air  that  may  be  free  from 
infective  germs  may  be  considerable  in  favorable  localities,  but,  as  there 
is  no  uniformity  in  the  distribution  of  floating  organisms,  no  given  volume 
can  be  relied  upon  as  absolutely  pure. 

ANTISEPTIC  SPRAYS. — With  the  view  of  procuring  absolute  purity,  at 
will,  of  all  air  coming  in  contact  with  a  wound,  Mr.  Lister  has  recom- 
mended to  fill  the  atmosphere  about  a  wound,  as  long  as  it  is  exposed,  with 
a  spray  of  a  carbolic  acid  solution,  believing  that  the  acid  has  the  property 
of  killing  whatever  germs  might  be  floating  in  the  air  thus  charged.  Of 
this  use  of  a  spray,  however,  Mr.  Cheyne,  in  his  "Antiseptic  Surgery,"  says 
(p.  73) :  "  Of  all  the  precautions  required  by  Mr.  Lister,  that  of  purifying 
the  air  by  means  of  a  carbolic  acid  spray  is  the  least  necessary,  for  there 
are  but  few  septic  particles  present  in  the  atmosphere,  and  even  though 
some  of  them  fall  on  to  a  wound,  they  may  be  rendered  inert  by  washing 
the  wound  with  carbolic  lotion.  .  .  .  If  at  the  present  time  he  were 
compelled  for  any  reason  to  give  up  some  one  precaution,  he  would  at 
once  throw  aside  the  spray,  as  'that  one  which  is  least  necessary,  and  which 
could  be  the  most  readily  dispensed  with." 

The  results  of  observations  made  by  others  have  not  confirmed  the 
supposed  power  of  the  carbolic  acid  spray  to  kill  floating  germs.  Experi- 
ments made  by  Stimson,'  of  New  York,  in  1879,  demonstrated  that  par- 
ticles of  atmospheric  dust,  after  having  passed  through  a  cloud  of  carbolic 
spray,  are  still  capable  of  exciting  putrefaction  in  liquids  upon  which 
they  lodge.  Duncan,  of  Edinburgh,  in  his  article  on  "  Genus  and  the 
Spray,"  already  referred  to,  reports  the  results  of  extended  and  repeated 
experiments,  which  definitely  prove  that,  so  far  as  the  destruction  of  float- 
ing germs  in  the  air  is  concerned,  the  spray  is  perfectly  ineffectual 
"When  we  consider  the  researches  published  by  the  German  Health 
Bureau,  it  seems  somewhat  doubtful  whether  the  carbolic  acid  spray  ever 
killed  a  single  healthy  bacterium  ;  the  vitality  of  certain  spores  is  certainly 
not  thereby  affected  "  (Belfield 2).  Instead  of  being  beneficial,  it  is  possi- 
ble that  a  spray  directed  upon  an  open  wound  may  be  positively  harmful 

1  An  Experimental  Inquiry  into  the  Value  of  the  Carbolic  Spray  as  a  Preventive 
of  Putrefaction.  Amer.  Journ,  Med.  Sciences,  January,  1880. 

1  Sepsis  and  Antiseptic  Surgery.     The  Medical  Record,  March  8,  1883,  p.  £U. 


68  THE   TREATMENT    OF    WOUNDS. 

by  reason  of  the  air-currents  which  it  produces,  for,  as  Duncan  observes, 
if  the  spray  is  made  to  play  across  a  beam  of  sunlight,  the  floating  dust 
may  be  seen  in  clouds  rushing  toward  and  being  whirled  along  with  it, 
so  that  one  can  hardly  doubt  that  the  margin  of  the  spray  is  the  most 
dangerous  position  in  which  a  wound  can  be  placed,  and  that  a  slight 
deflection  from  a  current  of  air  may  result  in  the  entrance  of  this  floating 
matter  to  recesses  where  the  solution  deposited  by  the  spray  may  never 
reach. 

The  observations  of  Miquel,  at  the  Montsouris  Observatory  (see  page 
39),  of  the  purification  of  the  atmosphere  from  floating  organisms  pro- 
duced by  rain-storms,  indicates  how  the  spray  may  be  made  a  valuable 
agent  in  promoting  the  purity  of  the  air  in  any  given  space.  By  means  of 
the  spray-producer  it  is  possible  to  have  a  local  rain-storm,  at  any  time  by 
means  of  which  the  floating  matter  in  the  air  may  be  mechanically  precipi- 
tated. The  temporary  comparative  purification  thus  secured  would  not 
be  increased  by  the  addition  of  a  small  proportion  of  any  antiseptic  sub- 
stance to  the  material  used  for  the  spray,  although  such  addition  would 
not  be  objectionable.  As  the  spray  washes  down  upon  the  surfaces  upon 
which  it  falls  the  floating  matter  which  it  carries  with  it,  it  should  not  be 
used  so  as  to  fall  upon  a  wound  In  the  cas*e  of  a  surgical  operation,  or  of 
the  dressing  of  a  wound,  its  use  should  be  preliminary  to  the  exposure 
of  the  wound. 

In  most  wounds,  whatever  germs  may  be  deposited  on  their  surfaces 
from  the  atmosphere  may  be  readily  destroyed  by  irrigation  with  antiseptic 
liquids,  but  in  some  the  deep  and  irregular  recesses  which  characterize 
them,  or  the  extent  of  the  natural  cavities  into  which  they  open,  as  in 
wounds  of  the  great  serous  and  joint  sacs,  make  perfect  irrigation  uncer- 
tain. In  dealing  with  such  wounds  the  additional  precaution  of  washing 
the  air  of  the  room  by  means  of  a  preliminary  spraying  promises  advantage. 


CHAPTER  V. 
WOUND-DISINFECTION— ANTISEPTICS. 

Antiseptics  in  General  .-—Comparative  Germicidal  Strength  of  Various  Agents- 
Strengths  Required  to  Restrain  Germ-Development — Local  Effect  of  Antiseptics 
on  Tissues — General  Toxic  Effects.  Special  Antiseptics : — Corrosive  Sublimate — 
Permanganate  of  Potassa — Carbolic  Acid — Its  Advantages — Its  Disadvantages — 
Carbolic  Intoxication — Chloride  of  Zinc— Salicylic  Acid — Boracic  Acid — Acetate 
and  Aceto-Tartrate  of  Alumina — Iodine  and  lodoform — lodoform  Intoxication — 
Naphthalin — Subnitrate  of  Bismuth. 

Ix  addition  to  the  resources  of  cleanliness  for  preserving  wounds  from 
becoming  the  seat  of  the  vital  activity  of  micro-organisms,  there  still  re- 
mains to  the  surgeon  the  employment  of  direct  applications  to  the  wound- 
surfaces  of  substances  which  have  the  power  either  to  destroy  them  out- 
right or  to  restrain  their  growth.  In  general  parlance  the  application  of 
the  term  antiseptics  is  restricted  to  these  substances. 

The  possibility  of  obtaining  antiseptic  results  in  a  wound  by  agents 
that  simply  restrain  the  growth  of  septic  organisms,  as  well  as  by  those 
that  destroy  them,  is  a  matter  of  great  practical  importance,  for  it  has  in- 
creased the  number  of  substances  available  for  antisepsis,  and  since  the 
preventive  effects  of  many  agents  can  be  accomplished  by  much  smaller 
amounts  than  their  destructive  effects,  it  has  been  found  possible  to  obtain 
their  antiseptic  effects  with  less  local  irritation  of  the  wound  itself  and  less 
liability  of  danger  from  absorption  of  poisonous  quantities  of  the  agent 
into  the  blood.1 


1  This  inhibitory  action  of  certain  agents  is  similar  to  the  effect  upon  certain  pro- 
cesses of  vegetable  life  exhibited  by  anaesthetics.  "  The  addition  of  ether  to  an  in- 
fusion containing  yeast,  at  once  arrests  the  process  of  fermentation.  On  removal  of 
the  anaesthetic,  by  evaporation  or  by  nitration,  the  activity  of  the  yeast  fungus  is  re- 
newed, and  fermentation  is  again  resumed.  If  an  aquatic  plant  be  placed  in  a  watery 
.solution  of  ether  or  chloroform,  its  absorption  of  carbonic  anhydride  and  its  exhala- 


70  THE   TREATMENT    OF   WOUNDS. 

In  estimating  the  usefulness  of  any  agent  as  an  antiseptic  application 
in  the  treatment  of  wounds,  three  things  have  to  be  taken  into  considera- 
tion. 

1.  Its  power  as  a  germicide  or  germ-restrainer. 

2.  Its  immediate  local  effect  on  the  wound  surfaces — neutral,  irritant, 
or  caustic. 

3.  Its  remote  constitutional  effect  when  absorbed  into  the  general  cir- 
culation. 

Some  general  considerations  under  each  of  these  should  receive  atten- 
tion before  taking  up  individual  antiseptics. 

1.  What  amounts  of  the  various  antiseptic  agents  are  necessary  to  intro- 
duce into  a  wound,  to  secure  the  destruction  or  resist  the  multiplication  of 
whatever  septic  germs  may  have  gained  access  to  it? 

The  fact  that  germs  of  different  species  manifest  different  degrees  of 
vital  resistance  to  chemical  reagents,  and  that  differences  in  the  physical 
condition  of  the  same  species  of  germs  at  different  times  likewise  cause 
variations  in  the  effects  produced  by  applications  made  to  them,  must 
always  be  br"ne  in  mind  in  the  clinical  application  of  experimental  re- 
searches as  affecting  the  precise  strength  of  an  agent  needed  to  antagonize 
possible  septic  germs. 

The  experiments  of  Dr.  George  M.  Sternberg1  give  the  following 
amounts  as  the  strengths  required  for  certain  reagents,  enumerated,  to 
destroy  the  vitality,  or  to  prevent  the  development  of  the  micrococcus  of 
pus.  The  fluid  containing  the  micro-organisms,  with  proper  precautions 
to  guard  against  errors,  was  subjected  by  this  experimenter  to  the  test 
liquids  for  a  space  of  two  hours.  The  following  table  exhibits  the 
strengths  needed  to  destroy  the  organisms  : 


tion  of  oxygen  cease.  The  plant  does  not  die  ;  it  merely  sleeps.  On  replacing  it  in 
pure  water,  its  natural  respiration  is  immediately  resumed.  The  germination  of 
seeds  may  also  in  a  similar  manner  be  arrested  by  surrounding  them  with  an  anaes- 
thetic atmosphere  "  (Lyman  :  Anaesthetics  and  Anaesthesia ;  The  International  Ency- 
clopaedia of  Surgery,  Vol.  I.,  p.  409). 

1  Experiments  to  determine  the  Germicide  Value  of  certain  Therapeutic  Agents. 
American  Journal  of  the  Medical  Sciences,  April,  1883,  p.  335. 


ANTISEPTIC    AGENTS. 
TABLE  OF  GEEMICIDAL   STRENGTHS. 


Reagent. 


Efficient  in  the 


proportion  of 
one  part  in 
Mercuric  bichloride  .....................  20  000 

Potassium  permanganate  ............  333 

Iodiue  ......................................  500 

Creosote  ..........  ...........  OQO 

Sulphuric  acid  .......................  200 

Carbolic  acid  ..............  .......  JQQ 

Hydrochloric  acid  ....................  JQQ 

Zinc  chloride  ....................  50 

Tinctura  ferri  chloridi  ..................  25 

Salicylic  acid  dissolved  by  sodium  borate  ............  25 

Citric  acid  ........................  g 

Chloral  hydrate  ......................  5 

The  following-named  reagents  failed  in  the  proportions  given  below, 
which  were  as  far  as  the  experiments  were  conducted  with  them  : 

Failed  in  the 
proportion  of 

Fowler's  solution  (arsenite  of  potassa)  ............  40  per  cent. 

Sodium  hyposulphite  ...........................  32 

Sodium  sulphite  (exsiccated)  .....................  10 

Ferric  sulphate  (saturated  solution)  ..............  1(5 

Potassium  iodide  ..............................  8 

Liquor  zinci  chloridi  ................    ..........  8 

Zinc  sulphate  ..................................  20 

Boracic  acid  (saturated  solution)  .................  4 

Sodium  borate  (saturated  solution)  ...............  4 

Sodium  salicylate  ..............................  4 

Similar  experiments  made  with  the  micrococcus  of  gonorrhea,  the 
micrococcus  of  septicaemia  in  the  rabbit,  the  bacterium  terroo,  and  upon  the 
organisms  developing  in  broken-down  beef-tea  wlu'ch  had  been  freely  ex- 
posed to  the  air,  showed  that  in  general  those  reagents  which  destroyed  the 
vitality  of  the  micrococcus  from  pus  are  equally  efficient  when  a  different 
micro-organism  is  used.  The  most  uniform  power  was  displayed  in  all 
the  cases  by  mercuric  bichloride  and  by  iodine,  which  the  author  presents 
as  germicide  agents  of  the  highest  value,  giving  as  the  proportion  in 


72  THE    TREATMENT    OF    WOUNDS. 

which  they  would  certainly  be  efficient  as  one  part  in  five  thousand  for 
mercuric  bichloride,  and  one  part  in  two  hundred  for  iodine. 

Experiments  made  to  determine  the  minimum  quantity  of  the  reagents 
named  required  to  prevent  the  development  of  the  various  micro-organ- 
isms gave  results  which  also  were  found  to  be  pretty  uniform  for  the 
three  different  organisms.  As  will  be  seen  in  the  subjoined  table,  boracic 
acid,  sodium  biborate,  and  salicylic  acid  dissolved  by  means  of  sodium 
biborate,  though  they  had  not  been  found  to  possess  any  germicide  value, 
even  in  four  per  cent,  solutions,  proved  to  be  potent  in  preventing  the 
development  of  septic  organisms.  This  power  is  more  marked  in  the  case 
of  the  bacterium  termo,  a  putrefactive  organism,  than  in  that  of  the 
micrococcus  of  pus. 

The  following  table  shows  the  minimum  quantity  required  to  prevent 
the  development  of  the  micrococcus  of  pua 

TABLE   OF   STRENGTHS   REQUIRED  TO  RESTRAIN   GERM-DEVELOPMENT. 

Efficient  in  the 

Reagent.  proportion  of 

one  part  to 

Mercuric  bichloride 35,000 

Iodine 4,000 

Sulphuric  acid 1,800 

Carbolic  acid 500 

Salicylic  acid  and  sodium  biborate,  equal  parts 200 

Boracic  acid 200 

Ferric  sulphate 200 

Sodium  biborate 100 

Alcohol 10 

Comparison  of  the  two  tables  shows  that  the  more  potent  germicides 
have  the  power  of  restricting  multiplication  in  quantities  considerably  less 
than  are  required  to  destroy  vitality. J  In  the  case  of  iodine,  the  difference 

1  The  following  table  of  results  obtained  by  Koch  in  the  laboratory  of  the  Imperial 
Board  of  Health  at  Berlin  (MittheUungen  aus  detn  kaiserUdien  Gesundheitsamle,  p. 
236,  Berlin,  1881)  may  be  compared  with  the  results  of  Sternberg  : 

Strength  of  reagent.  exposure.  Effect. 

Corrosive  sublimate,  aqueous  solution,  1  to  100.  1  day.  Total  destruction  of  life. 

Permanganate  of  potash,  1  to  20 "  " 

Permanganate  of  potash,  1  to  100 2  days.  No  effect. 


ANTISEPTIC    AGENTS.  73 

is  eightfold ;  in  that  of  carbolic  acid,  fivefold ;  in  that  of  sulphuric  acid, 
fourfold,  etc. 

The  substances  included  in  this  list  tested  by  Steinberg  include  the 
most  of  the  more  common  reagents  that  have  heretofore  been  in  use  in 
solution,  as  antiseptic  lotions,  in  the  treatment  of  wounds.  The  results  of 
these  experiments  are  of  great  value  in  giving  a  standard  by  which  to 
judge  the  merits,  as  antiseptics,  of  various  agents,  and  also  by  which  to 
determine  the  strength  of  the  antiseptic  solution  to  be  used  in  any  given 
instance ;  though  prudence  may  require  that  solutions  of  considerably 
greater  strength  than  the  minimum  quantities,  determined  as  sufficient  for 
antiseptics  in  the  flasks  used  for  these  laboratory  experiments,  be  used  for 
the  disinfection  of  actual  wounds. 

In  addition  to  these  soluble  agents,  a  new  class  of  agents,  insoluble, 
powerless,  or  comparatively  insoluble,  has  recently  been  added  to  the  list 
of  antiseptics.  These  now  include  iodoform,  naphthalin,  and  the  subni- 
trate  of  bismuth.  They  remain  to  be  subjected  to  a  similar  series  of  tests 
to  determine  the  minimum  strengths  in  which  they  must  be  present  to 
exert  certainly  an  inhibitory  effect  upon  germ-growth. 

2.  The  effect  which  a  substance  introduced  into  a  wound  as  an  antiseptic 
may  have  on  the  exposed  surfaces  of  the  wound  must  be  taken  into  consider- 


Btrength  of  reagent.  ex^e.  Kfft'Ct- 

Osmic  acid,  1  to  100 1  day.          Total  destruction  of  life. 

Turpentine,  oil  of •">  days. 

Chlorine  water,  freshly  made 1  day. 

'Bromine,  1  to  50 

Iodine  water. 

Iodine,  alcoholic  solution,  1  to  100 Hindered  growth  only. 

Chloride  of  lime r>  days.          Total  destruction  of  life. 

Chloride  of  iron (i  days. 

Arsenic,  1  to  100 10  days. 

Sulphurous  acid  water Vei7  slightly  efficacious. 

Sulphuric  acid,  1  to  100 1°  days.          Hindered  growth. 

Boracicacid,  1  to  20 6  days. 

Borax,  1  to  20 15  days.          Xo  effect- 
Quinine,  1  to  100 10  days-         Total  destruction  of  life. 

Carbolic  acid,  aqueous  solution,  from  1  to  100  to  1  to  20,  is  sufficient  to  destroy 
organisms  that  have  not  passed  into  the  spore  condition.  For  the  sure  destruction  of 
the  spores  of  the  anthrax  bacilli  a  strength  of  1  to  10  is  necessary. 


74  THE   TREATMENT    OF    WOUNDS. 

ation  in  choosing  one  for  use,  as  well  as  its  effect  upon  the  germ  supposed  to 
be  present. 

A  pronounced  irritating  or  caustic  effect  may  render  an  agent  unfit  for 
use  upon  living  tissues.  Even  if  but  slightly  irritating,  the  increased 
serous  flow,  which  its  application  may  provoke,  will  seriously  embarrass 
the  attempt  to  prevent  the  development  of  septic  conditions  in  it.  The 
property  of  producing  upon  wound-surfaces  a  thin  film  of  coagulated  albu- 
men uncongenial  to  the  growth  of  germs,  as  a  protection  of  the  surfaces 
covered  by  it,  and  which,  by  pressure,  tends  to  restrain  effusion,  has  ex- 
tended greatly  the  usefulness  of  so  feeble  an  antiseptic  as  chloride  of  zinc ; 
the  freedom  from  irritation  of  iodoform  and  bismuth  powder,  and  their 
properties  of  absorbing  moisture  and  exercising  compression  upon  the 
surfaces  to  which  they  are  applied,  thus  restraining  secretion,  add  greatly 
to  their  antiseptic  powers. 

3.  The  possibility  of  the  production  of  general  toxic  symptoms  by  absorj)- 
tion  of  the  agents  used  as  local  antiseptic  applications  is  always  to  be  borne 
in  mind  as  a  consideration  checking  the  unlimited  use  of  these  agents. 

The  amount  of  danger  attending  the  use  of  particular  agents  will 
be  considered  in  connection  with  each.  In  general,  however,  it  may  be 
stated  that  the  larger  the  surface  exposed  to  the  action  of  the  agent,  and 
the  more  prolonged  the  exposure,  the  greater  the  danger  of  absorption 
in  toxic  quantities  becomes. 

The  special  properties  of  individual  antiseptics  will  now  be  considered, 
including,  however,  only  such  as  have  been  found  by  experience  to  be  of 
value  as  wound  applications.  They  will  be  taken  up  in  the  following 
order :  Corrosive  Sublimate,  Permanganate  of  Potassa,  Carbolic  Add,  Chlo- ' 
ride  of  Zinc,  Salicylic  Acid,  Boracic  Acid,  Acetate  of  Alumina,  Iodine  and 
Iodoform,  Naphthalin,  Subnitrate  of  Bismuth. 

CORROSIVE  SUBLIMATE. 

Though  the  efficient  anti-putrefactive  properties  of  the  mercuric  bichlo- 
ride, or  corrosive  sublimate,  had  been  known  for  a  long  time,  its  employ- 
ment in  the  treatment  of  wounds  had  been  prevented  by  fears  of  its  toxio 
effect  through  absorption,  and  also  by  the  ardent  advocacy  of  the  sufficient 
merits  of  other  agents. 

The  publication  of  the  researches  of  Koch  upon  the  bacilli  of  anthrax, 
the  spores  of  which,  though  they  were  unaffected  by  other  antiseptics,  were 


.       COEBOSIVE   SUBLIMATE.  75 

killed  in  a  few  minutes  in  a  solution  of  corrosive  sublimate,  1  to  1,000,  and 
were  prevented  from  developing  by  a  solution  of  1  to  5,000,  has  inspired 
surgeons  to  trials  of  this  agent,  the  results  of  which  have  been  very  satis- 
factory. In  the  Hamburg  General  Hospital,  during  seven  months  begin- 
ning with  November,  1881,  Schede  and  Kummell  used  no  other  antiseptic, 
except  for  the  spray  and  for  the  bath  for  instruments,  for  which  purposes 
carbolic  acid,  1  to  20,  was  used.  These  surgeons  employed  solutions  vary- 
ing in  strength  from  1  to  100  to  1  to  5,000.  Although  large  quantities  of 
the  stronger  solution  were  used,  and  the  cases  were  closely  watched  for 
constitutional  toxic  symptoms,  in  only  two  cases  out  of  over  two  hundred 
did  any  salivation  occur.1 

These  surgeons  report  that  the  healing  of  the  wounds,  in  the  dressing 
of  which  the  sublimate  is  used,  is  accomplished  with  a  certainty  and  uni- 
formity unknown  under  any  other  dressing.  Esinarch  and  Neuber,  of 
Kiel,  have  recommended  it  strongly  as  an  adjuvant  to  the  peat  dressing. 
Out  of  212  cases  of  extensive  wounds  treated  by  them  with  the  sublimate 
and  peat  dressing,  in  only  11  cases  was  the  dressing  changed  more  than 
once.  No  toxic  symptoms  were  observed  in  any  of  these  cases. 

Weir,  in  the  New  York  Hospital,  has  used  it  with  satisfactory  re- 
sults.2 

The  sublimate  solution  is  free  from  odor,  and  does  not  irritate  the 
wound.  By  its  use  the  wound-secretions  mai'kedly  decrease,  and  wounds 
previously  offensive  become  speedily  sweet  In  some  instances  it  pro- 
duces a  roughness  of  the  skin,  and  in  an  easily  irritated  skin  an  eczema 
may  also  be  provoked.  For  purposes  of  irrigation  a  solution  of  1  to  1,000 
(about  8  grains  to  the  pint  of  water)  will  afford  a  standard  solution  of  re- 
liable antiseptic  strength.  A  solution  of  the  same  strength  should  be 
used  for  immersing  the  sponges  and  compresses,  and  also  for  the  perma- 
nent preservation  of  the  silk  used  for  sutures,  after  they  have  first  been 
soaked  for  two  hours  in  a  solution  of  1  to  100  (76  grains  to  the  pint). 
Any  external  dressings  applied  may  be  impregnated  with  the  sublimate,  as 
previously  described.  For  the  disinfection  of  instruments  it  cannot  be 
employed  on  account  of  its  corrosive  action  on  the  metal  of  which  they  are 
made. 


1  H.  Kummell:    Ueber  eine  neue  Verbandmethode,  etc.     ArcMv  fur  RUnisehe  Chi- 
rurgie,  Band  xxviii.,  Heft  3. 

2  The  Weak  Points  in  a  Lister  Dressing,  and  the  Advantages  of  Corrosive  Subli- 
mate as  an  Antiseptic.     New  York  Medical  Journal,  May  19,  1883,  p.  549. 


76  THE    TREATMENT   OF    WOUNDS. 

PERMANGANATE  OF  POTASSA. 

Since  permanganate  of  potassa  was  brought  to  the  notice  of  the  pro- 
fession by  Mr.  Condy,  in  1857,  its  antiseptic  powers  have  been  recognized, 
and  it  has  been  much  used  for  purposes  of  irrigation,  in  aqueous  solutions 
of  from  5  to  20  parts  to  100.  The  rapidity  with  which  it  becomes  decom- 
posed when  brought  into  contact  with  organic  substances  unfits  it  for  use 
as  an  agent  to  secure  prolonged  antiseptic  effects. 

CARBOLIC  ACID. 

The  use  of  carbolic  acid  as  an  antiseptic  owes  its  introduction  to  Le- 
maire,  of  France,  who  published  a  work  entitled  "De  1'acide  phenique  "  in 
1863.  Lemaire  was  the  first  to  use  carbolic  acid,  and  was  the  first  to 
realize  the  truth  of  the  germ  theory  as  applied  to  wounds. '  The  first  in- 
terest in  the  use  of  this  agent  had  in  great  degree  subsided,  inasmuch  as 
the  use  of  it,  applied  in  the  way  recommended  by  Lernaire,  had  failed  to 
give  satisfactory  results,  when  it  was  taken  up  by  Mr.  Lister,  in  1866,  in 
his  wards  in  the  Royal  Infirmary  of  Glasgow,  and  by  him  brought  through 
various  modifications  of  use  until  a  complete  system  of  wound-dressing, 
based  upon  its  antiseptic  properties,  known  as  the  Listerian  method,  was 
ultimately  elaborated. 

This  agent  still  remains  the  one  in  more  general  use  as  an  antiseptic 
than  any  other,  chiefly  through  the  impetus  received  by  the  marked  and 
certain  immunity  from  septic  accidents  in  wounds  which  surgeons  were, 
for  the  first  time,  able  to  secure  by  its  use  according  to  the  methods 
prescribed  by  Mr.  Lister.  Whether  a  more  accurate  knowledge  of  the 
character  of  the  agencies  which  are  capable  of  disturbing  the  repair  of 
wounds,  and  the  power  of  other  agents  to  equally  or  more  certainly  coun- 
teract them,  shall  cause  carbolic  acid  to  become  measurably  obsolete  in 
the  future  or  not,  to  carbolic  acid  itself  will  always  attach  the  interest 
which  comes  from  having  been  the  agent  through  which  the  possibili- 
ties of  antiseptics  in  the  treatment  of  wounds  were  first  demonstrated ; 
and  whether  in  future  the  technique  of  Mr.  Lister  in  the  dressing  of 
wounds,  when  antisepsis  is  desired,  shall  continue  to  be  adopted  or  not, 
to  him  will  ever  remain  the  credit  of  having  first  appreciated  the  full  rela- 
tions of  sepsis  to  wound-disturbances,  and  of  having  devised  a  method  by 

1  Cheyne :  Antiseptic  Surgery,  p.  356. 


CARBOLIC    ACID.  77 

which  septic  infection  in  a  wound  was  certainly  guarded  against,  and  of 
having  inaugurated  a  new  era  in  wound-treatment  in 'which  it  was  elevated 
from  the  position  of  an  empirical  art  to  that  of  an  exact  science. 

Carbolic  acid  is  a  product  of  the  destructive  distillation  of  coal  Pure 
carbolic  acid  is  absolute  phenol,  C0H6O.  It  is  supplied  as  a  pinkish  crys- 
talline mass,  readily  soluble  in  fifteen  parts  of  water  at  the  ordinary  tem- 
perature. When  subjected  to  slight  heat  it  liquefies,  and  may  be  made 
permanently  liquid  by  adding  to  it  five  per  cent,  of  water. 

The  ordinary  commercial  acid  contains  an  homologous  substance,  cre- 
sol,  which  does  not  crystallize,  and,  though  very  deliquescent,  does  not 
dissolve  readily  in  water.  It  has  equal  antiseptic  properties,  but  is  more 
irritating  and  causes  numbness  and  tingling  of  the  skin  in  a  much  greater 
degree  than  the  pure  acid  does.  One  part  of  the  ordinary  commercial 
acid  will  dissolve  with  some  difficulty  in  twenty  parts  of  water. 

Carbolic  acid  is  freely  soluble  in  glycerine  and  in  alcohol,  and  readily 
blends  with  oil  in  any  proportion.  The  following  practical  remarks  as  to 
its  preparations  and  their  uses  are  mainly  from  MacCormac's  "Antiseptic 
Surgery "  :  Water  possesses  no  very  strong  attraction  for  carbolic  acid  ; 
the  latter  is  readily  given  oft*  by  it,  hence  watery  solutions  seem  to  act 
more  intensely  on  the  skin,  or  any  surface  to  which  they  are  applied. 
When  the  acid  does  not  dissolve  in  twenty  parts  of  water,  but  partly  re- 
mains suspended  in  the  form  of  oil-globules,  impurity  to  that  extent  is 
indicated,  and  the  solution  should  be  filtered  before  using,  as  the  undis- 
solved  particles  act  as  a  caustic. 

The  best  way  of  preparing  either  oily  or  watery  mixtures  is  to  first 
put  a  few  ounces  of  oil  or  water  into  the  jar  or  bottle,  and  then  add  the 
full  quantity  of  acid,  previously  melted  by  heat.  Mix  tjie  two  thoroughly, 
and  afterward  add  the  remainder  of  the  oil  or  water,  otherwise  it  is  diffi- 
cult to  properly  blend  the  oil  or  water  with  the  acid. 

The  watery  solutions  are  of  two  strengths :  one  being  five  per  cent.,  or 
1  part  in  20,  and  the  other  two  and  a  half  per  cent.,  or  1  part  in  40.  The 
five  per  cent,  solution  is  employed  for  purifying  the  hands  of  the  surgeon 
and  his  assistants  before  and  during  an  operation  ;  also  to  disinfect  the 
surface  of  that  region  of  the  body  where  the  operation  is  about  to  be  per- 
formed, and  all  parts  which  will  be  included  in  the  subsequent  dressing— 
also  for  supplying  the  steam  spray.  In  a  solution  of  this  strength  sponges 
are  preserved,  also  silk  and  drainage-tubes. 

The  1  in  40  solution  is  used  for  the  purpose  of  irrigating  a  wound, 


78  THE    TREATMENT    OF    WOUNDS. 

washing  the  sponges  used  during  an  operation,  soaking  the  gauze  which,  is 
first  applied  to  the  surface,  and  for  tilling  the  tray  in  which  the  instruments 
required  are  placed.  Glycerin  in  equal  proportion  to  the  carbolic  acid 
may  often  be  added  with  advantage  to  the  watery  solution.  It  helps  to 
prevent  the  too  rapid  volatilization  of  the  acid,  and  counteracts  to  some 
extent  its  irritating  properties. 

A  solution  of  carbolic  acid  in  alcohol,  1  to  5,  is  used  for  the  purpose  of 
purifying  wounds  inflicted  some  twenty-four  or  thirty-six  hours  before 
coming  under  treatment. 

Carbolic  acid  and  glycerin  in  the  proportions  of  1  to  5  and  1  to 
10  is  used  as  a  dressing  for  wounds  in  the  neighborhood  of  the  anus, 
penis,  etc. 

Carbolic  oil  consists  of  a  mixture  of  carbolic  acid  and  olive  oil  in 
various  proportions.  The  1  to  5  oil  is  chiefly  known  as  the  solution  in 
which  catgut  is  permanently  preserved.  It  has  been  shown  by  Koch,1 
however,  that  solutions  of  carbolic  acid  in  oil  or  alcohol  are  absolutely 
inert  in  respect  to  their  action  on  bacteric  life,  either  on  the  spores  or  the 
fully  developed  organisms.  Anthrax  spores  introduced  into  oily  solutions 
of  carbolic  acid,  of  thymol,  and  of  salicylic  acid,  in  each  at  the  end  of 
three  months  were  still  found  capable  of  development.  Koch,  however, 
remarks  that  "when  the  oily  solution  came  in  contact  with  substances 
containing  water,  as,  for  instance,  the  tissues  of  the  human  body  in 
wounds,  etc.,  then  it  undoubtedly  gave  up  part  of  the  acid  to  these,  and 
in  this  way  an  antiseptic  effect  would  be  produced.  In  all  cases,  however, 
in  which  dry  substances,  such  as  silk,  catgut,  instruments,  etc.,  have  car- 
bolic oil  applied  to  them,  not  the  least  antiseptic  effect  is  to  be  expected 
even  upon  the  mos^t  vulnerable  micro-organisms." 

The  possibility  of  catgut  having  been  made  from  the  intestines  of  an- 
thracized  sheep  renders  special  caution  in  its  perfect  disinfection  neces- 
sary. Zweifel,  of  Erlangen,  Kocher,  of  Berne,  and  Volkrnann,  of  Halle, 
have  already  reported  cases  of  anthrax-infection  of  wounds  by  means  of 
catgut 

The  use  of  gauze  and  other  materials  impregnated  with  carbolic  acid  as  a 
wound  dressing  will  be  described  in  a  subsequent  chapter  (Chap.  X.).  The 
rapid  deterioration  of  the  antiseptic  strength  of  such  dressings  by  the  volatil- 
ization of  the  carbolic  acid  has  been  shown,  particularly  by  Dr.  R  F.  Weir,* 


1  Ueber  Disinfection.     Afttthettungen  atis  dem  kaiserliehen  Gesundheitsamte,  1881. 

2  Remarks  on  Antiseptic  Dressings.     New  York  Medical  Journal,  January,  1880. 


CARBOLIC    ACID.  79 

of  New  York,  who  found  that  in  gauze  that  had  been  impregnated  after 
Lister's  formula,  and  kept  in  a  tight  box  wrapped  up  in  rubber  cloth, 
there  remained  at  the  end  of  three  months  but  1.44  per  cent,  of  carbolic 
acid.  Another  specimen,  similarly  prepared  and  preserved,  showed  at  the 
end  of  three  weeks  1.82  per  cent  The  ordinary  gauze  sold  at  the  shops 
was  found  by  Kopff  to  have  but  one-half  of  one  per  cent,  of  acid.  Only 
that  which  has  been  freshly  prepared,  therefore,  should  ever  be  used. 

ADVANTAGES  OF  CARBOLIC  ACID  AS  AN  ANTISEPTIC. — The  properties  of 
carbolic  acid  which  commend  it  for  use  as  an  antiseptic  are  : 

1.  Its  reliability.     Comparatively  weak  aqueous  solutions,  1  to  20  and 
1  to  40,  may  be  depended  upon  with  certainty  to  destroy  all  micro-organ- 
isms (except  such  most  resistant  spores  as  the  anthrax,  which  need  not  be 
ordinarily  considered  in  connection  with  wounds),  while  much  weaker  so- 
lutions suffice  to  prevent  development  as  long  as  the  reagent  continues  to 
be  present. 

2.  Its  diffusibility.      The    miscibility   of    the    reagent-solutions   with 
wound-secretions,  and  the  absence  of  any  escharotic  or  coagulating  effect 
from  the  dilute  solutions  used,  favor  its  penetration  into  all  parts  of  what- 
ever wound  may  be  treated  with  it,  whereby  complete  and  thorough  dis- 
infection of  all  parts  of  the  wound  is  certainly  obtained. 

DISADVANTAGES. — 1.  The  local  irritation  which  it  excites.  Carbolic  acid, 
when  brought  in  contact  with  albuminous  fluids,  as  serum  or  pus,  forms  a 
compound  with  the  albumen — phenol-albuminate — so  that  its  addition  in 
larger  quantities  and  in  greater  strength  is  necessary  to  secure  complete 
disinfection  of  wounds,  if  they  have  already  become  septic.  The  iiiita- 
tion  which  the  use  of  solutions  of  the  required  strength,  1  to  20  to  1  to 
40,  produces,  determines  increased  capillary  oozing,  and  an  excessive  and 
prolonged  serous  flow  from  the  wound  surfaces.  In  this  respect  its  use 
violates  one  of  the  most  important  indications  of  wound-treatment,  to 
diminish  the  amount  of  putrescible  material  in  a  wound.  To  overcome 
this,  greater  complexity  of  drainage,  and  of  external  dressings  to  a  wound 
are  demanded,  and  the  most  watchful  care  against  the  possible  entrance 
of  septic  organisms  rendered  necessary.  Eczema  and  erythema  of  the 
skin  covered  by  the  carbolic  dressings  is  not  an  infrequent  effect.  It  be- 
numbs the  skin,  and  is  followed  by  general  branny  exfoliation  of  the  su- 
perficial layers  of  epidermis.  This  is  particularly  likely  to  be  disagreeably 
marked  upon  the  hands  of  the  surgeon  using  it 

2.  Its  volatility  lessens  its  usefulness  as  an  agent  to  secure  permanent 


80  THE    TREATMENT    OF    WOUNDS. 

antisepsis,  making  frequent  renewal  of  the  dressings  necessary,  which 
renewals  violate  another  fundamental  principle  of  wound-treatment,  that 
of  rest  Unless  the  dressings  are  frequently  changed,  organisms  speedily 
appear  in  the  discharges  that  accumulate  under  the  dressings. '  The  ne- 
cessity of  restraining  the  volatilization  of  this  antiseptic  by  enveloping  the 
dressings  charged  with  it  in  an  impermeable  material — macintosh — keeps 
the  parts  thus  confined  in  a  state  of  moist  warmth,  which  promotes  exuda- 
tion and  favors  decomposition  by  maintaining  a  condition  favorable  for 
the  occurrence  of  putrefaction  as  soon  as  the  antiseptic  is  sufficiently  ex- 
hausted. By  keeping  the  skin  underneath  it  moistened  with  retained 
secretions  it  establishes  also  a  favorable  channel  for  the  introduction  of 
organisms  from  without.  Its  volatility  makes  absorbent  dressing  materials 
that  have  been  charged  with  it  entirely  unreliable  for  antiseptic  dressings 
after  they  have  been  prepared  for  more  than  a  few  days.  A  surgeon  in  ordi- 
nary practice  is  thus  prevented  from  keeping  it  in  stock  for  emergencies. 

3.  Its  toxic  qualities.  The  absorption  of  carbolic  acid  in  poisonous 
quantities  is  more  frequently  observed  when  large  cavities  or  extensive 
wounds  are  washed  out  or  are  exposed  to  the  action  of  the  reagent  under 
a  pressure  that  favors  its  absr  rption.  Some  persons  seem  peculiarly  sus- 
ceptible to  the  influence  of  carbolic  acid,  and  in  them  quite  a  small  quan- 
tity will  suffice  to  excite  symptoms  of  poisoning.  Children  and  women 
seem  more  especially  liable  to  its  noxious  influence.  Many  fatal  cases  of 
poisoning  by  absorption  of  carbolic  acid,  when  used  as  an  antiseptic  appli- 
cation, have  been  recorded.  The  severe  cases  are  characterized  by  symp- 
toms of  profound  collapse,  which  speedily  terminates  in  death  by  failure 
of  the  respiration.  In  the  less  severe  cases  gastric  derangements  first 
appear,  as  loss  of  appetite,  frequent  nausea,  or  incessant  vomiting ;  there 
is  an  increase,  often  enormous,  in  the  secretion  of  saliva.  More  or  less 
stupor  or  giddiness,  noises  in  the  head,  or  other  signs  of  cerebral  disturb- 
ance. The  secretion  of  urine  is  diminished,  and  very  often  becomes  of  a 
dark  olive-green  color.  It  may  be  passed  in  this  condition,  or  may  become 
dark  only  after  standing  for  some  time.  There  is,  however,  no  direct 
relation  between  the  toxic  effects  of  the  carbolic  acid  and  the  amount  of 
the  discoloration.  It  is  met  with  when*there  are  no  other  symptoms  ;  or 
the  urine  may  be  clear,  while  other  well-marked  signs  of  carbolic-acid 
poisoning  are  present.  Abandonment  of  the  use  of  the  acid  is  at  once 


1  Cheyfle :  Antiseptic  Surgery,  p.  238  et  gey. 


CAEBOLIC    POISONING — CHLOEIDE    OF   ZINC.  81 

required  when  toxic  symptoms  arise.  Little  benefit  is  to  be  expected 
from  any  other  treatment 

In  Mr.  Lister's  practice,  according  to  Cheyne,  carbolic-acid  poisoning 
is  a  thing  of  very  rare  occurrence,  only  two  cases  having  been  recognized 
in  which  serious  toxic  symptoms  were  due  to  it  The  reason  given  for  this 
immunity  is,  that  Mr.  Lister  brings  carbolic  acid  as  little  as  possible  in 
contact  with  wounds,  applying  it  freely  to  everything  which  may  come  in 
contact  with  the  wound,  rather  than  to  the  wound  itself.  He  does  not 
irrigate  wounds,  nor  inject  them,  nor  even  wash  away  the  blood  and  dirt 
from  the  line  of  incision. 

The  importance  of  the  disadvantages  that  attend  the  use  of  carbolic 
acid  in  the  treatment  of  wounds  is  so  great  that,  with  the  increasing  know- 
ledge of  the  requirements  for  preventing  the  septic  infection  of  wounds, 
and  of  the  value  of  other  agents  for  that  purpose,  its  use  deserves  to  be- 
come very  much  circumscribed.  Only,  perhaps,  for  use  in  the  antiseptic 
bath  for  the  immersion  of  metallic  instruments  can  it  not  now  be  replaced 
by  less  objectionable  substances. 

CHLORIDE  OF   ZINC. 

The  germicidal  power  of  chloride  of  zinc,  according  to  Steinberg,  is  but 
half  that  of  carbolic  acid,  a  strength  of  1  to  50  being  required  to  destroy 
the  micrococcus  of  pus.  It  is  very  soluble  in  water,  and  its  stronger  solu- 
tions are  powerfully  caustic.  It  has  been  commonly  employed  in  the 
strength  of  8  to  100  (40  grains  to  the  ounce).  This,  while  it  destroys  with 
certainty  all  organisms  that  may  be  present,  forms  by  its  reaction  with  the 
albumen  of  the  tissue  to  which  it  is  applied  a  white  translucent  film  of 
zinc-albuminate,  which  not  only  restrains  exudation  and  protects  mechan- 
ically the  underlying  tissue,  but  also  forms  to  them  an  antiseptic  shield 
that  is  capable  of  resisting  for  many  days  the  development  of  micro-organ- 
isms.1 The  caustic  effect  of  the  reagent  unfits  it  for  use  on  freshly  cut 

1  Kocher,  in  his  paper  on  the  treatment  of  wounds  already  referred  to.  quotes  the 
experiments  of  Boillat,  in  which  a  specimen  of  this  zinc-albuminate,  covered  simply 
with  a  glass-receiver  and  kept  at  the  ordinary  temperature  of  the  room,  showed  the 
first  evidences  of  the  development  of  micrococci  thirty  days  later  than  a  correspond- 
ing specimen  of  simple  albumen,  although  anthrax  spores  had  been  sown  directly  on 
the  surface  of  the  former.  A  specimen  of  phenol-albuminate,  prepared  like  the  zinc- 
albuminate,  remained  free  from  organisms  only  one  day  longer  than  the  simple  albu- 
men. 

6 


82  THE    TREATMENT    OF    WOUNDS. 

surfaces,  if  their  union  by  first  intention  is  desired.  In  wounds  in  the 
vicinity  of  the  mouth  and  anus,  to  which  protective  dressings  are  inappli- 
cable or  insufficient,  its  value  is  especially  great.  It  has  been  commonly 
employed  in  the  8  to  100  strength  for  the  disinfection  of  wounds  that  have 
been  for  some  time  exposed  to  septic  influences,  or  in  which  septic  change 
has  already  taken  place.  Kocher  speaks  in  terms  of  the  highest  praise  of 
the  value  of  very  dilute  solutions  of  chloride  of  zinc,  1  to  500,  for  irrigating 
large  suppurating  cavitiea  The  absence  of  poisonous  properties  in  the 
reagent  permits  its  use  without  limit  till  every  vestige  of  pus  has  disap- 
peared. By  the  use  of  some  antiseptic  external  dressing  to  exclude  the 
entrance  of  new  infectious  material  to  the  cavities,  a  perfect  and  rapid 
healing  of  the  cavity  may  be  secured.  Generally  a  single  irrigation  with 
the  chloride  of  zinc  solution  suffices.  Only  when  recurrence  of  high  tem- 
perature takes  place  is  a  repetition  needed. 

The  combination  of  qualities  possessed  by  chloride  of  zinc,  of  restrain- 
ing the  further  production  of  putrefiable  material  and  of  rendering  what- 
ever material  of  the  kind  there  may  already  be  present  unfit  to  support 
the  life  of  septic  organisms,  with  certain  germicidal  strength,  makes  it  an 
antiseptic  agent  of  the  greatest  value. 

SALICYLIC   ACID. 

Salicylic  acid  was  introduced  by  Thiersch,1  of  Leipzig,  as  a  substitute 
for  carbolic  acid,  the  methods  of  its  use  being  the  same.  Though  of  much 
less  germicidal  power  than  carbolic  acid,  by  reason  of  its  comparative 
freedom  from  toxic  qualities,  the  possibility  of  its  use  in  greater  quantities 
in  many  instances  is  sufficient  to  make  it  an  efficient  antiseptic.  Wounded 
surfaces  are  not  irritated  by  it,  nor  is  the  granulating  process  disturbed. 
The  results  obtained  by  it  have  not  been  as  good  as  those  obtained  by  car- 
bolic acid.  The  experiments  of  Sternberg  show  that  the  solution  of  sali- 
cylic acid,  1  to  300,  that  has  been  used,  is  practically  inert 

It  has  been  more  recently  used  as  a  dry  powder-dressing  with  more 
decided  antiseptic  effects.  It  is  not  applicable  to  fresh  wounds  in  which 
union  by  first  intention  is  desired,  as  it  acts  mechanically  to  prevent  appo- 
sition. It  is  not  efficient  in  the  prevention  of  erysipelas.  It  does  not  ad- 

1  Klinische  Ergebnisse  der  Litter'scften  Wundbehandlung  und  uber  den  Ersatz  der 
Carbolsaure  durch  Salicylsdure.  Volkmann'a  Sammlung  Idinischer  Vortrage,  Nos.  84 
and  85.  1875. 


BORACIC  ACID — ACETATE  OF  ALUMINA.          83 

here  firmly  to  the  tissues  to  which  it  is  applied,  and  hence'  is  easily  washed 
away  by  any  increased  secretion.  When  cavities  are  packed  with  it,  in 
powder,  and  covered  in  by  salicylic  wool,  the  first  dressing  may  remain 
in  place  for  from  one  to  two  weeks  without  decomposition  taking  place  in 
the  wound  secretions,  and  with  rapid  progress  of  healing.  In  general  its 
use  in  large  quantities  has  been  unattended  with  toxic  symptoms. 


BORACIC  ACID. 

Boracic  acid  has  been  highly  praised  by  the  late  William  Warren  Greene, 
of  Portland,  Me.,1  as  a  reliable  germicide,  cheap,  free  from  all  unpleasant 
taste  or  odor,  stable,  and  devoid  of  any  irritating  or  poisonous  quality 
within  the  limits  of  ordinary  doses.  By  Sternberg  its  value  was  found  to 
consist  solely  in  its  ability  to  restrain  the  development  of  organisms,  which 
it  possesses  in  a  marked  degree.  By  Mr.  Lister  it  is  used  as  an  applica- 
tion to  superficial  granulating  surfaces.  It  may  be  dissolved  in  water  in 
the  proportion  of  nearly  4  to  100  parts  to  form  a  lotion  ;  but  it  finds  its 
greatest  use  in  the  shape  of  borated  cotton  to  afford  a  permanent  antisep- 
tic protective  dressing. 

ACETATE    AND    ACETO-TARTRATE   OF   ALUMINA. 

The  introduction  of  acetate  of  alumina  as  an  antiseptic  application  to 
wounds  is  due  to  Maas,  of  Freiburg.  It  is  cheap,  unirritating,  and  non- 
poisonous,  but  can  only  be  used  in  the  moist  form  as  it  decomposes  in  the 
dry  state.  If  ten  parts  of  hydrate  of  alumina  are  mixed  with  eight  parts 
of  dilute  acetic  acid,  and  allowed  to  stand  for  twenty- four  to  thirty -six 
hours,  at  a  temperature  of  from  68°  to  90°  F.,  the  filtered  solution  ob- 
tained will  be  of  fifteen  per  cent,  strength.  The  hydrated  alumina  may  be 
obtained  by  precipitation  from  a  solution  of  common  alum  by  carbonate 
of  soda. 

For  application  to  wounds  a  solution  of  two  and  one  half  per  cent, 
strength  is  used.  Compresses  wet  with  the  solution  are  laid  over  the 
wound  and  covered  in  with  macintosh.  The  amount  of  wound-secretion  is 
usually  very  small,  and  the  dressings  required  are  infrequent.  The  aceto- 
tartrate  of  alumina  is  a  crystallized  salt,  soluble  in  all  proportions,  and 
possessed  of  marked  antiseptic  properties.  It  owes  its  introduction  as  an 


'Boracic  Acid  in  Surgery.     Boston  Medical  and  Surgical  Journal,  1880. 


84  THE    TREATMENT    OF    WOUNDS. 

antiseptic  to  Kiimmell,  of  Hamburg,  who  has  used  it  as  a  three  per  cent, 
and  a  five  per  cent,  solution  for  purposes  of  irrigation  with  children  and  in 
all  cases  in  which  the  toxic  qualities  of  carbolic  acid  render  that  agent  un- 
advisable.  As  an  antiseptic  dressing  one-half  to  three  per  cent,  solutions 
gave  very  satisfactory  results.  Mixed  with  charcoal  in  proportions  of  three 
parts  of  the  salt  to  seven  of  charcoal  (the  charcoal  having  been  previously 
baked  for  several  hours),  it  forms  an  antiseptic  absorbent  powder-dressing 
of  the  greatest  value  for  filling  in  wound-cavities  when  primary  union  is 
impossible.  A  first  dressing  with  the  aluminated  charcoal  may  often  be 
allowed  to  remain  undisturbed  for  one  or  two  weeks.  In  small  wounds 
complete  healing  will  be  accomplished  as  under  a  scab.  It  makes  an 
exceptionally  favorable  dressing  for  wounds  involving  the  anal  region,  and 
particularly  after  operations  for  extirpation  of  the  rectum,  in  which  cases 
the  wound-cavity,  after  hemorrhage  has  been  controlled,  is  packed  with 
the  powder,  which  is  held  in  place  with  a  layer  of  cotton- wool,  some  im- 
permeable tissue,  and  a  T  bandage. 

IODINE  AND   IODOFORM. 

IODINE  has  been  long  in  use  as  a  topical  application  to  wounds.  In 
1854  it  was  praised  by  Duroy  ; l  in  1871,  Richardson  advocated  its  use  as 
a  most  valuable  agent  in  the  treatment  of  wounds,  alleging  that  it  deo- 
dorizes, controls  discharge,  destroys  decomposing  products,  and  does  no 
systemic  injury.11  Bryant,*  for  purifying  wound-surfaces  has  employed 
for  years  an  iodine  lotion  made  by  adding  twenty  drops  of  the  tincture 
to  the  ounce  of  water  (pouring  the  tincture  into  a  basin  full  of  water, 
until  the  latter  is  of  a  light  sherry  color,  is  a  sufficient  practical  guide), 
and  prefers  it  to  any  other,  as  being  always  at  hand,  and  both  simple  and 
effectual.  A  sponge  wrung  out  of  this  lotion  (made  with  hot  water),  and 
held  to  a  wound  for  a  minute,  completely  checks  all  oozing  of  blood, 
and  tends  more  than  anything  else,  except  prolonged  exposure  to  the  at- 
mosphere, to  the  formation  of  that  glaze  upon  the  surface  of  the  wound 
which  so  much  conduces  to  satisfactory  repair. 

1  Experiences  et  Considerations  nouveUes  pour  servir  d  Vhittoire  de  riode.  Union 
ffidicak,  Paris,  T.  vffi.,  1857. 

*  On  the  Science  and  Art  of  Healing  Wounds.  Transactions  St.  Andrew's  Med- 
ical Graduates  Association,  1871,  v.,  p.  49. 

3  International  Encyclopaedia  of  Surgery,  1882,  ii.,  p.  27.     Article  on  Wounds. 


IODOFORM.  85 

The  antiseptic  properties  of  iodine,  according  to  Sternberg's  experi- 
ments are  many  fold  greater  than  those  of  carbolic  acid — as  a  germicide 
five  times,  and  as  a  germ-restrainer  eight  times  as  great — but  they  have 
attracted  general  attention  only  since  the  introduction  into  use,  as  an  an- 
tiseptic, of  its  compound,  iodoform,  the  teriodide  of  formyl,  CJH3t  which 
contains  ninety-six  per  cent,  of  iodine. 

IODOFORM,  when  in  solution,  undergoes  gradual  decomposition,  evolving 
iodine,  so  that  when  a  wounded  surface  is  covered  with  iodoform  a  kind 
of  antiseptic  reservoir  is  established,  which,  constantly  and  slowly  giving 
off  iodine  in  a  nascent  state,  effectually  hinders  putrefactive  changes  in 
the  wound.1  The  credit  of  having  introduced  iodoform  as  an  antiseptic 
dressing,  is  due  to  Professor  A.  Von  Mosetig-Moorhof,  of  Vienna,  who 
advocated  its  use  first  in  a  series  of  articles  published  in  the  Weiner  Medi- 
cinische  Wochenschrift  in  1880  and  1881,  and  more  recently  in  a  clinical 
lecture  published  in  Volkmann's  series.8 

The  advantages  possessed  by  iodoform  caused  its  immediate  and  ex- 
tensive adoption  ;  by  it  was  introduced  a  new  method  of  antiseptic  dress- 
ing, the  dry-pouxler  dressing,  which  more  perfectly  met  the  requirements 
of  a  wound-dressing,  than  any  method  that  had  preceded  it.  It  restrained 
wound-secretion  and  thus  diminished  the  amount  of  putrefiable  material 
in  a  wound  ;  it  destroyed  the  vitality  of  whatever  putrefactive  germs  were 
already  present  in  the  wound,  without  itself  irritating  the  wound  ;  it  was 
capable  of  forming  an  external,  antiseptic,  protective  dressing  ;  its  decom- 
position or  its  volatilization  was  so  slow  that  the  frequency  of  the  dress- 
ings required  was  greatly  lessened. 

Iodoform  is  easily  soluble  in  ether,  and  in  both  the  fixed  and  essential 
oils,  less  readily  in  alcohol,  and  to  a  very  slight  degree  in  water.  It  has 
not  the  least  local  irritant  action,  but  exercises  an  anaesthetic  effect  upon 
the  surfaces  to  which  it  is  applied.  On  account  of  its  slight  solubility  in 
•water  and  in  the  animal  fluids  it  is  not  adapted  for  disinfecting  instru- 
ments and  sponges,  the  hands  of  the  surgeon,  or  the  adjacent  integument, 
or  as  an  application  to  surfaces  already  decidedly  septic.  Upon  fresh 
wound-surfaces,  or  upon  surfaces  that  have  been  long  exposed  after  they 
have  been  disinfected  by  some  other  agent,  as  corrosive  sublimate,  carbolic 

1  Sands :  On  the  Value  of  Iodoform  as  a  Dressing  for  Wounds.  The  Medical  Record, 

1882,  xxi.,  p.  309. 

*Der  lodoform-Verband.     Volkmann's  Wnfccher  Vortrage,    No.  211,   January, 

1882. 


86  THE    TREATMENT    OF    WOUNDS. 

acid,  or  chloride  of  zinc,  the  powdered  iodofonn  may  be  lightly  dusted 
(from  a  pepper-box).  A  slight  layer  of  iodoform  will  not  interfere  with 
union  by  first  intention  when  apposition  of  the  surfaces  can  be  obtained. 
In  such  case,  after  bringing  the  wound-surfaces  together,  with  such  pro- 
visions for  drainage  as  may  seem  best,  the  dressing  is  completed  by  cover- 
ing the  surface  with  several  layers  of  iodoform-gauze,  or  other  similar 
antiseptic  absorbent  substance.  Over  all  a  layer  of  some  impermeable 
tissue,  the  whole  confined  by  a  snugly  applied  bandage.  This  dressing 
may  be  renewed  on  the  second  or  third  day,  and  afterward  every  five  or 
eight  days,  or  even  after  longer  intervals,  as  circumstances  may  determine. 
Pain  in  the  wound,  or  an  elevation  of  temperature,  after  it  has  been  for 
some  time  normal,  are  indications  calling  for  a  change  of  dressing. 

In  open  wounds  the  cavities,  after  having  been  lightly  sprinkled  with 
the  powder,  are  filled  with  the  iodoform-gauze,  and  the  whole  covered  in 
as  before.  Such  wounds  remain  free  from  pain,  the  scanty  discharge 
which  takes  place  is  serous  in  character,  the  surrounding  integument  re- 
mains free  from  inflammatory  swelling,  and  the  process  of  granulation 
proceeds  rapidly  and  without  interruption.  When,  however,  the  repara- 
tive  process  is  far  advanced,  ultimate  cicatrization  is  hastened  by  the  use 
of  some  other  agent 

Iodoform  is  especially  adapted  for  use  in  the  treatment  of  wounds  in- 
volving the  mouth  or  anal  region,  in  which  cases  plugging  the  wound 
with  iodoform-gauze  suffices  to  keep  it  aseptic.  Frequent  removal  of  the 
dressing  even  is  unnecessary. 

DISADVANTAGES  OF  IODOFORM. — 1.  It  is  less  absolute  in  its  power  to  pro- 
tect wounds  against  the  invasion  of  erysipelas  than  against  suppuration 
and  putrefactive  disturbances. 

2.  Its  odor  is  pervasive  and  lasting,  and  quite  disagreeable  to  most  per- 
sons.    Musk,  Peruvian  balsam,  various  essential  oils,  as  bergamot,  clove, 
and  peppermint,  have  been  proposed  as  corrigents.     Mosetig-Moorhof  orig- 
inally used  Tonquin  bean  for  the  purpose.    Schork  says  that  if  0.05  gramme 
of  carbolic  acid  be  rubbed  up  with  10  grammes  of  iodoform,  and  2  drops 
of  oil  of  peppermint  be  added,  the  unpleasant  odor  is  entirely  covered 
and  is  not  again  developed  even  under  a  higher  temperature. 

3.  Its  toocic  qualities  early  claimed  attention  on  account  of  the  great 
freedom  with  which  the  earlier  employment  of  the  agent  was  characterized. 
Various  degrees  of  toxic  action  have  been  recorded,  and  experience  has 
demonstrated  that  its  use  must  be  guarded  with  certain  cautions,  if  risks 


IODOFORM   INTOXICATION NAPHTHALIN.  87 

of  fatal  consequences  are  to  be  avoided.  It  acts  by  absorption  into  the 
general  circulation  of  poisonous  quantities  from  the  wound-surfaces. 
Poisonous  doses  cause  rapid  and  feeble  heart-action,  coma,  and  paralysis 
of  the  organs  of  respiration.  Autopsies  have  demonstrated  in  such  cases 
the  lesionS  of  meningitis  and  fatty  degenerations  of  the  heart,  liver,  and 
kidneys.  But  the  most  remarkable  manifestations  of  poisoning  in  the  hu- 
man subject  are  due  to  perverted  cerebral  action,  taking  the  form  of  men- 
tal derangement.  Every  degree  of  intoxication  has  been  observed,  from 
simple  exaggeration  of  nervous  excitability  to  the  condition  of  acute  mania. 
In  the  lighter  cases  patients  are  restless  and  uncomfortable,  complaining 
of  headache,  loss  of  appetite,  wakefulness,  and  the  constant  taste  of  iodo- 
form.  Such  symptoms  often,  but  not  always,  precede  those  which  are  met 
with  in  bad  cases,  which  are  nearly  identical  with  the  symptoms  of  delirium 
tremens.  From  such  a  condition  many  persons  recover,  while  others  die, 
often  suddenly,  from  exhaustion  or  coma.  No  antidote  to  the  poison  has 
been  discovered,  and  the  only  treatment  of  any  avail  is  that  of  preventing 
further  intoxication,  and  supporting  the  patient's  vital  powers  by  alcoholic 
stimulants  until  the  crisis  is  past.  Thus  far  it  has  not  been  ascertained 
definitely  what  amount  of  iodoform  is  necessary  to  cause  poisoning,  and 
the  susceptibility  to  its  action  appears  to  vary  greatly  in  different  cases. 
Old  persons  are  especially  liable  to  suffer  from  iodoform-poisoning,  while 
such  is  not  the  case  with  children,  as  far  as  can  be  inferred  from  the  limited 
statistics  thus  far  published.  In  the  present  state  of  our  knowledge  it 
should  be  employed  with  great  caution,  and  in  such  a  manner  that  it  can 
be  readily  removed  from  the  wound  in  case  symptoms  of  poisoning  should 
supervene. ' 

According  to  Neuber,"  of  Kiel,  not  more  than  forty-five  grains  of  iodo- 
form should  ever  be  sprinkled  upon  a  fresh  wound-surface. 

NAPHTHALIN. 

Napthalin  is  a  coal-tar  product,  much  resembling  paraffin  in  appear- 
ance, save  that  it  is  much  more  crystalline.  It  is  insoluble  in  water  or 
animal  juices,  but  readily  dissolves  in  ether,  hot  alcohol,  and  various  fatty 
oils.  Fischer,  of  Strassburg,  first  recommended  it  for  use  as  an  antiseptic 

1  Sands.     Op.  citat. 

2  Erfahrungen  uber  lodoform-und  Torfverbande,  etc.     Archio  fur  JdiniscJie  CM- 
rurgie,  1882,  xxvii.,  p.  757. 


88  THE    TREATMENT    OP    WOUNDS. 

wound-dressing. '  It  was  adopted  by  Professor  Liicke  in  his  surgical  wards 
in  Strassburg,  and  thence  has  come  into  general  vise.  In  the  United  States 
it  has  been  made  the  subject  of  study  and  comment  by  Park,2  of  Chicago, 
and  Fowler,3  of  Brooklyn. 

It  is  to  be  used  as  a  dry  powder-dressing,  being  dusted,  in  fine  powder, 
on  the  surfaces  of  the  wound,  or  packed  hi  quantities  without  limit  into 
wound-cavitiea  Gauze  impregnated  with  it  may  be  used  for  absorbent 
and  protective  dressings. 

Though  its  antiseptic  qualities  are  inferior  to  those  of  carbolic  acid  or 
iodoform,  yet  in  addition  to  the  general  advantages  of  the  powder-dressing 
which  it  shares  with  iodoform,  it  has  the  great  advantage  that  no  general 
toxic  effects  ever  follow  its  use,  and  that  it  is  almost  a  specific  against  ery- 
sipelas. 

It  is  not  adapted  for  use  in  wounds  the  union  of  which  by  first  inten- 
tion is  desired.  To  insure  its  protective  action  it  is  important  that  it  be 
introduced  into  every  part  of  the  wound,  and  care  is  to  be  taken  that  its 
tendency  to  form  crusts  does  not  cause  retention  of  the  wound-secretions. 
Its  freedom  from  toxic  qualities  commends  it  as  a  substitute  for  iodo- 
form in  cases  in  which  the  use  of  the  latter  agent  is  unadvisable  or  must 
be  discontinued. 

A  pure  article  of  naphtha! in  only  should  be  used.  Pure  naphthalin 
remains  white  permanently ;  an  impure  article  turns  red.  The  applica- 
tion of  the  impure  article  is  likely  to  occasion  pain  and  irritation  of  the 
wound  and  eczema  of  the  surrounding  skin.  No  such  effects  attend  the 
use  of  pure  naphthalin. 

SUBXITRATE  OF  BISMUTH. 

The  subnitrate  of  bismuth  is  advocated  by  Professor  Kocher,4  of  Berne, 
as  an  antiseptic  agent  not  inferior  to  any  previously  employed,  and  excell- 
ing all  in  the  simplicity  of  its  application,  its  certain  antiseptic  effect,  and 

1  Untersuchungen  uber  die  Wirkung  des  Naphthalin.  BerUner  klinische  Wochen- 
sehrift.  1882.  xix. ,  p.  113. 

8  Naphthalin  as  an  Antiseptic  for  Surgical  Dressings.  The  Weekly  Medical  Review, 
1883,  p.  54. 

3  Naphthalin  in  the  Treatment  of  Wounds.     Annals  of  Anatomy  and  Surgery,  1883, 
vii.,p.  242. 

4  Veber  die  einfachslen  Mittd  zur  Erzielung  einer  Wundhettung  durch  Verklebung 
ohne  Darmrohren.     Volkmann's  Sammlung  klinischer  Vortrage,  No.  224. 


8UBNITBATE    OF    BISMUTH.  89 

its  innocuousness.  Its  special  field  is  as  an  application  to  fresh  wounds 
for  restraining  the  development  of  organisms,  while  for  the  disinfection  of 
hands,  instruments,  surrounding  skin,  and  of  wounds  that  are  already  sep- 
tic, other  agents  must  be  employed.  Its  insolubility  prevents  its  effect 
from  extending  beyond  the  region  to  which  it  is  directly  applied,  there- 
fore, when  it  is  used,  special  care  to  prevent  accumulation  of  blood  and 
wound-secretion  is  necessary.  This  Kocher  accomplishes  by  leaving  all 
wounds  open  temporarily,  protected  by  a  bismuth  dressing,  and  closing 
them  only  after  the  first  outpouring  of  the  secretions  is  arrested.  The 
bismuth  exercises  a  desiccating  and  astringent  effect  upon  the  wound-sur- 
faces and  assists  in  limiting  the  amount  of  secretion.  Under  its  use  the 
secretion  from  the  wound-cavity  ceases  in  from  twelve  to  thirty-six  hours. 
Wounds  may  then  be  closed  without  any  further  provisions  for  drainage. 
It  is  to  be  used  suspended  in  water  ;  the  salt  should  have  been  finely  pow- 
dered, with  special  care  for  the  purpose  ;  should  then  be  gradually  and 
most  thoroughly  triturated  with  water,  till  all  grittiness  has  disappeared, 
and  an  emulsion-like  mixture  can  be  produced  by  simply  adding  water. 
If  a  bottle  containing  such  a  mixture  is  shaken,  the  bismuth  will  be  uni- 
formly and  rapidly  suspended  through  the  fluid. 

A  one  per  cent,  watery  mixture,  thus  prepared,  will  answer  all  the  de- 
mands of  thorough  antisepsis.  In  the  course  of  operations  the  surfaces 
of  the  wound  may  be  moistened  at  intervals  with  the  .lotion  by  sprinkling 
it  from  a  bottle,  and  when  the  dressings  are  changed  similar  manipula- 
tions may  be  repeated.  The  application  of  the  salt  to  a  fresh  wound- 
surface  causes  at  first  a  smart  burning  sensation,  but  after  the  first  ap- 
plication this  is  no  longer  experienced.  After  the  lips  of  a  wound  have 
been  brought  together,  bismuth  may  be  spread  upon  the  line  of  sutures 
in  the  form  of  a  thick  paste  applied .  by  means  of  a  brush.  This  method 
may  also  be  followed  when  a  wound  has  healed  to  a  narrow,  superficial 
granulating  surface.  In  recent  wounds  the  dressing  is  completed  by 
applying  a  protective  covering  of  gauze  or  other  absorbent  material, 
which  has  been  dipped  in  a  ten  per  cent,  mixture  of  bismuth,  the  mois- 
ture being  pressed  out  before  being  applied  ;  over  this  a  layer  of  cotton- 
wool, and  some  impermeable  tissue,  the  whole  kept  in  place  by  a  roller 
bandage. 

The  subnitrate  of  bismuth  should  not  be  applied  in  unlimited  quanti- 
ties. It  is  absorbed  to  some  extent  by  fresh  wound-surfaces,  and  if  ap- 
plied in  large  quantities  to  extensive  surfaces  will  produce  toxic  effects, 


90  THE    TREATMENT    OF    WOUNDS. 

characterized  by  acute  stomatitis  analogous  to  the  chronic  f orm  of  lead- 
poisoning,  intestinal  catarrh,  and  desquamative  nephritis.  There  may  be 
slight  transient  renal  disturbances  produced,  as  manifested  by  a  blackish 
discoloration  of  the  urine,  with  albumen  and  epithelial  casts,  unattended 
by  other  general  symptoms.  These  toxic  effects  subside  rapidly  after  the 
removal  of  the  bismuth,  without  leaving  any  permanent  after-effects.  None 
of  them  have  been  occasioned  since  the  lavish  use  of  strong  mixtures  and 
the  packing  of  cavities  with  the  undiluted  powder  has  been  abandoned. 


PART  I. 

IIST     OEISTEHAL 


SECTION  II. 

THE  PRACTICE  OF  WOUKD-TREATHENT. 


CHAPTER  VI. 
THE  ABEEST  OF  HEMORRHAGE. 

Spontaneous  Hcemostasis— Surgical  Hcemostasis— Exposure  to  Air— Cold— Hot  Water- 
Iodine — Alcohol — Turpentine — Mechanical  Pressure — Compresses  —  Tampons — 
Acnpressnre — Forcipressure — Ligation — Catgut  Ligatures — Plugging  Vessels — Tor- 
sion— Coagulants — The  Cautery — Interrupting  Blood-current—  Position — Forced 
Flexion — Digital  Compression — Tourniquets — Elastic  Bandage — Acupressure  — 
Ligation — Cardiac  Sedatives. 

THE  conditions  which  demand  the  attention  of  the  surgeon  in  the  case 
of  every  wound  present  themselves  to  him  in  the  following  order  : 

1.  The  arrest  of  haemorrhage. 

2.  The  general  condition  of  the  patient 

3.  The  cleansing  of  the  wound. 

4.  The  apposition  of  its  surfaces. 

5.  The  means  of  protection  required  to  prevent  disturbance  of  the 

healing. 

6.  The  relief  of  disturbances  of  the  healing,  if  any  be  present 

THE  ARREST  OF  HEMORRHAGE. 

In  most  wounds  haemorrhage  is  an  immediate  symptom,  and,  in  many, 
demands  the  instant  and  active  interference  of  the  surgeon  for  its  con- 
trol. 

Its  extent  will  depend  on  the  number,  size,  and  character  of  the 
wounded  vessels ;  and  the  character  of  the  surgical  aid  demanded  -will 
depend  upon  the  extent  to  which  the  natural  tendencies  to  spontaneous 
arrest  are  deficient,  the  object  of  the  surgeon  being  simply  to  supply  such 
deficiencies  in  the  manner  that  may  cause  the  least  disturbance  in  the 
future  repair  of  the  wound. 

In  every  wound  a  spontaneous   effort   at  heemostasis  takes  place,  in 


94  THE   TREATMENT    OP    WOUNDS. 

which  the  wounded  vessels,  the  perivascular  tissues,  and  the  blood  itself 
are  all  engaged.  A  divided  artery  contracts  and  greatly  diminishes  its 
lumen  and  withdraws  itself  within  its  sheath.  A  vein  collapses  so  that  its 
walls  fall  together.  Connective-tissue  strands  and  muscular  fibrils  fall 
over  the  cut  ends  of  the  vessels  and  tend  to  entangle  the  fibrin  of  the 
escaping  blood.  The  irritated  muscular  and  elastic  tissue  of  the  wounded 
region  contracts  and  compresses  the  vessels  that  it  embraces.  This  spon- 
taneous vascular  contraction,  aided  by  the  compression  exercised  by  the 
contraction  of  the  surrounding  wounded  tissue,  suffices  alone  to  check 
haemorrhage  from  the  capillaries  in  healthy  tissues.  As  the  result  of  the 
action  of  these  influences,  the  bleeding,  though  very  free  at  the  moment 
of  the  infliction  of  the  wound,  quickly  becomes  greatly  diminished  in 
amount  When  vessels  too  large  to  be  controlled  by  such  influences  are 
wounded,  and  the  haemorrhage  continues  until  much  blood  is  lost,  the 
force  of  the  heart's  beat  becomes  weakened,  until  the  impulse  to  the  blood 
current  which  it  gives  may  become  too  feeble  to  send  the  wave  of  blood  as 
far  as  the  wounded  vessel,  and  thus  the  bleeding  spontaneously  ceases. 
The  blood  itself  brings  the  crowning  agent  for  completing  the  process  of 
arresting  its  own  flow,  in  the  coagula  that  begins  to  form  as  soon  as  the 
first  vigorous  gush  is  slackened.  These  become  fixed  by  the  irregular  sur- 
faces of  the  wound,  and,  extending  into  the  interior  of  the  severed  vessels 
as  far  as  to  the  first  collateral  branches,  temporarily  plug  them  up.  These 
coagula  serve  only  a  temporary  purpose,  those  within  the  vessels  becoming 
eventually  replaced  by  the  new  granulation-tissue  which  the  wounded  tis- 
sue of  the  vessels,  and  especially  their  inner  tunics,  are  stimulated  to  pro- 
duce for  the  ultimate  permanent  repair  of  the  wound. 

The  effective  exercise  of  this  quality  of  coagulation  for  arresting  haem- 
orrhage is  thwarted  only  when  the  rapidity  of  the  blood  current  that 
reaches  the  opening  in  the  vessel  is  too  great  to  permit  a  coagulum  to  ac- 
cumulate, or  its  force  is  so  great  as  to  sweep  away  whatever  may  have 
already  been  formed.  This  latter  cause  is  especially  illustrated  by  the  re- 
curring haemorrhages  that  take  place  from  vessels  that  had  ceased  to  bleed 
when  the  heart's  action  had  become  faint  through  shock  or  loss  of  blood  ; 
with  the  establishment  of  reaction  the  heart-beats  become  strong  again, 
and  the  impulse  of  the  blood-waves  become  sufficiently  great  to  sweep 
away  the  coagula  previously  formed  ;  the  haemorrhage  recurs,  and  though 
it  may  soon  cease,  it  will  continue  to  recur,  unless  adequate  means  to 
prevent  it  be  taken,  until  the  patient  dies  of  anaemia. 


MEANS    OF   ARRESTING   HAEMORRHAGE.  95 

The  agencies  which  nature  provides  for  the  spontaneous  arrest  of  haem- 
orrhage include,  therefore,  the  following : 

1.  Immediate  diminution  in  the  size  of  the  opening  by  the  intrinsic 

contraction  or  collapse  of  the  walls  of  the  injured  vessel 

2.  Immediate  and  direct  compression  from  without  by  contraction  of 

surrounding  tissue. 

3.  Secondary  diminution  in  the  force  and  volume  of  the  blood  current 

by  heart  faintness. 

4.  Temporary  plugging  by  coagulation  of  the  escaping  blood. 

5.  Permanent  occlusion  by  the  exudation  and  organization  of  plastic 

material  at  the  seat  of  the  wound  in  the  vessel. 

The  agencies  which  the  surgeon  likewise  will  find  of  benefit  must  de- 
rive their  value  either  from  the  compression  they  produce,  the  contraction 
of  the  vessels  they  excite,  the  interference  with  the  blood  supply  they  ac- 
complish, or  the  increased  coagulability  of  the  blood  they  occasion. 

The  means  for  arresting  haemorrhage  naturally  divide  themselves,  there- 
fore, into  means  of  direct  vascular  contraction,  of  compression,  of  plugging 
the  open  orifice  of  the  vessel,  and  of  interruption  to  the  blood  current. 

MEANS  OF  DIRECT  VASCULAR  CONTRACTION. — This  class  includes  contact  of 
atmospheric  air,  cold  and  hot  applications,  and  such  local  irritants  as 
iodine,  alcohol,  and  turpentine. 

Exposure  to  Air. — The  contraction  of  soft  parts  when  exposed  to  the 
air  is  very  marked,  and  the  continued  exposure  of  a  bleeding  surface  to 
cool  air  produces  a  strong  haemostatic  effect,  which  is  increased  if  the  air  is 
kept  in  motion  as  by  a  fan.  When  a  wound  is  filled  with  coagula,  underneath 
which  bleeding  is  still  taking  place,  the  thorough  removal  of  the  clots  and 
the  exposure  of  the  bleeding  points  are  often  speedily  followed  by  the  ces- 
sation of  the  haemorrhage.  In  all  cases  where  there  is  present  haemorrhage, 
the  first  duty  of  the  surgeon  is,  if  possible,  to  fully  and  clearly  expose  the 
bleeding  point  by  the  removal  of  whatever  clots,  compresses,  or  bandages 
may  have  previously  accumulated  in  or  about  the  wound.  Should  the  mere 
exposure  to  the  air  not-  be  sufficient  to  cause  the  hsemorrhage  to  cease, 
it  is  in  the  best  position  to  receive  the  benefit  of  other  applications.  Where 
the  possibility  of  recurrence  of  hsemorrhage  in  a  wound  is  to  be  feared, 
the  free  exposure  of  the  wound-surfaces  to  the  air  for  some  hours  furnishes 
the  most  reliable  means  of  guarding  against  it.  Though  the  wound  be 
not  closed  until  after  many  hours,  the  process  of  healing  may  yet  continue 
without  material  disturbance,  and  union  by  first  intention  be  secured. 


96  THE   TREATMENT   OP    WOUNDS. 

Cold  as  a  haemostatic  has  always  been  recognized  as  of  great  value.  It 
may  be  applied  by  irrigating  the  wound  with  cold  water,  by  applying 
sponges  or  compresses  wrung  out  of  cold  water,  by  the  application  of 
small  pieces  of  ice  to  the  bleeding  surface,  or  by  enveloping  the  part  in 
bags  containing  pounded  ice.  Although  cold,  thus  applied,  causes  the  soft 
parts  to  contract  and  the  blood-vessels  to  shrink,  its  application  for  any 
length  of  time  tends  to  increase  shock,  and  to  depress  the  vitality  of  the 
wound-surfaces,  and  thus  to  diminish  the  vigor  of  the  subsequent  repair 
of  the  wound.  The  after-effect  of  the  cold  is  to  lessen  the  tone  of  the 
capillaries  and  predispose  them  to  inflammatory  conditions.  The  use  of 
cold  applications  for  heemostatic  purposes  is  therefore  to  be  resorted  to 
only  in  exceptional  cases  in  default  of  other  resources. 

Hot  water  is  even  more  efficient  as  an  hromostatic  than  cold.  Attention 
has  but  recently  been  called  to  its  merits  by  Keetley,1  in  England,  and  by 
Hamilton3  and  Hunter/  in  the  United  States.  It  combines  in  an  eminent 
degree  the  properties  of  stimulating  the  contraction  of  the  soft  tissues  of 
the  exposed  surface,  and  of  exciting  the  vital  contractility  of  the  vessels 
both  directly  by  contact,  and  indirectly  through  the  vaso-motor  nerves. 
It  produces  a  permanently  stimulating  effect  upon  the  vitality  of  the  sur- 
faces to  which  it  is  applied ;  it  favors  primary  union  in  the  wound ;  and 
in  no  class  of  cases  is  its  value  more  marked  than  in  those  of  threat- 
ened shock  and  of  exhaustion  from  haemorrhage.  The  temperature  of  the 
water  should  be  as  great  as  can  be  borne  by  the  hand  without  pain,  from 
125°  to  139°  F.  Hamilton  used  sponges  dipped  in  hot  water  at  almost  a 
boiling  temperature,  and  applied  by  forceps  to  the  bleeding  points.  But 
as  the  water  is  intended  to  act  as  a  stimulant,  and  not  mechanically  by 
coagulating  the  albuminoids  of  the  blood,  so  high  a  temperature  is  not 
needed.  The  most  effective  means  of  applying  it  is  by  means  of  com- 
presses of  muslin  or  linen,  or  towels  of  size  sufficient  to  cover  the  whole 
wound-surface,  that  all  parts  may  experience  the  effect  of  the  application 
simultaneously.  To  obtain  the  full  effect,  it  is  important  that  one  com- 
press be  quickly  succeeded  by  another  till  permanent  arrest  of  the  bleed- 
ing is  secured. 

Hot  water  answers  the  requirements  of  a  wound-application  more  per- 
fectly than  any  other  agent.  The  simple  precaution  to  free  it  from  hurtful 

1  London  Practitioner,  February,  1879. 

*  Buffalo  Medical  and  Surgioal  Journal,  April,  1870. 

1  Philadelphia  Modloal  Times,  November  22,  1870. 


MEANS    OF   COMPRESSION.  97 

organisms  before  it  is  used  is  alone  needed  to  make  it  entirely  unobjec- 
tionable. 

Iodine  added  to  hot  water  increases  its  haemostatic  effect,  -while  it  also 
disinfects  it.  Sufficient  of  the  iodine  may  be  poured  into  a  basinful  of 
water  to  make  the  latter  of  a  light  sherry  color.  A  sponge  wrung  out  of 
this  lotion  (made  with  hot  water),  and  held  to  a  wound  for  a  minute,  com- 
pletely checks  all  oozing  of  blood,  and  tends  more  than  anything  else,  ex- 
cept prolonged  exposure  to  the  atmosphere,  to  the  formation  of  that  glaze 
upon  the  surface  of  the  wound  which  so  much  conduces  to  satisfactory 
repair.1 

Alcohol  excites  to  action  the  contractility  of  the  vessels  and  the  peri- 
vascular  tissues,  while  it  acts,  in  addition,  as  an  antiseptic.  It  may  be  ap- 
plied on  a  sponge  pressed  upon  the  bleeding  surface. 

Turpentine  is  strongly  recommended  by  Billroth2  as  capable  of  exciting 
a  peculiarly  energetic  contraction  of  the  divided  capillaries.  It  may  be 
applied  on  bits  of  absorbent  material  pressed  against  the  bleeding  points. 
It  is  a  heroic  remedy  causing  severe  pain,  and  exciting  severe  inflammation 
in  the  wound  and  its  vicinity. 

MEANS  OF  COMPKESSION. — Compression  may  be  accomplished  by  agents 
that  either  stimulate  the  wounded  tissues  to  more  energetic  contraction, 
or  that  may  exert  direct  mechanical  pressure  upon  the  bleeding  sur- 
faces. 

The  first  class  of  agents  includes  again  atmospheric  air,  cold  and  hot 
applications,  and  certain  irritants,  since  these  agents  cause  the  surround- 
ing tissues  to  contract  with  the  same  energy  as  they  do  the  bleeding 
vessels.  The  contraction  of  the  perivascular  tissues  is  a  very  important 
element  in  accomplishing  the  spontaneous  arrest  of  bleeding.  The  range 
of  application  and  the  value  as  haemostatics  of  the  agents  which  have  been 
considered  as  stimulants  to  contraction  .of  the  vessels  directly  is  thus 
greatly  increased  by  their  effect  upon  the  surrounding  tissues,  through  the 
contraction  of  which  physiological  compression  of  the  vessels  is  secured. 
To  supplement  this,  however,  means  of  compression,  applied  from  without, 
are  necessary  whenever  the  size  of  the  vessels  is  too  great  to  admit  of  their 
control  by  physiological  means,  or  the  wounded  tissues  are  non-contractile. 
This  is  supplied  by  some  form  of  mechanical  pressure,  the  consideration  of 
the  varieties  of  which  is  next  to  be  taken  up. 

1  T.  Bryant:  Article  on  Wounds.    Internal.  Encyclopaedia  of  Surgery,  vol.  ii.,  p.  2' 

*  Surgical  Pathology  (Hackley,  1871),  p.  36. 
7 


93  THE    TREATMENT   OF    WOUNDS. 

* 

MECHANICAL  PRESSURE. — Properly  applied  pressure  is  sufficient  to  control 
any  haemorrhage.  It  may  be  applied  by  means  of  compresses,  tampons, 
bandages,  the  fingers  of  the  surgeon,  needles  thrust  into  the  tissues,  for- 
ceps, and  ligatures.  The  method  of  its  application  will  depend  on  the 
character  and  anatomical  relations  of  the  bleeding  vessels  ;  when  the  bleed- 
ing comes  from  several  points,  or  when  it  is  a  general  oozing,  which  per- 
sists notwithstanding  the  use  of  means  to  excite  tissue  contractility  in  the 
wound,  a  compress  is  of  great  value. 

Compresses  may  be  made  of  any  substance  that  permits  of  being  formed 
into  a  firm  pad  of  proper  size  to  be  introduced  into  the  wound.  Folds  of 
linen  or  cotton  cloth  are  generally  available.  Sponges  and  masses  of 
charpie  are  often  used.  All  clots  should  be  turned  out  of  the  wound,  and 
the  first  layer  placed  directly  upon  the  orifices  of  the  bleeding  vessels. 
Each  additional  layer  of  the  compress  should  be  larger  than  the  preced- 
ing, as  it  is  built  up  till  it  projects  above  the  surrounding  integument. 
The  whole  should  then  be  firmly  bandaged.  In  cases  where  compresses 
are  applied  to  wounds  of  a  limb,  the  roller-bandage  should  invariably  first 
be  applied  at  the  distal  extremity  of  the  limb,  and  be  carried  up  the  limb, 
over  the  compress  and  above  it  for  some  distance. 

Compresses  are  to  be  considered  only  as  temporary  expedients,  for 
their  use  is  in  violation  of  every  principle  of  wound-treatment  except  that 
of  haemostasis.  At  the  earliest  moment  they  should  be  removed  from  the 
wound.  If  the  wounded  vessels  are  of  such  size  as  to  render  a  recurrence 
of  the  haemorrhage  from  them  likely  to  take  place,  they  should  be  secured 
by  ligature  as  soon  as  the  necessary  procedures  are  practicable. 

In  wounds  of  slight  extent  sufficient  compression  to  control  bleeding 
may  often  be  exerted  by  bringing  the  surfaces  into  apposition  by  sutures, 
and  then  supporting  them  by  compress  and  bandage  applied  upon  the 
surface.  • 

Tampons  are  plugs  which  are  crowded  into  cavities,  such  as  the  narcs, 
the  rectum,  or  the  vagina,  from  some  part  of  whose  walls  bleeding  is  taking 
place.  They  act  by  the  direct  pressure  which  they  exert  upon  the  bleed- 
ing vessels. 

Haemorrhage  from  larger  arteries  and  veins  is  best  controlled  by  com- 
pression limited  to  the  bleeding  vessel,  and  applied  directly  to  it.  The 
finger  of  the  surgeon  instinctively  applies  itself  for  the  purpose  of  making 
such  compression  upon  the  orifice  of  the  severed  vessel,  and,  for  immediate 
temporary  haemostasis,  by  its  intelligence,  its  power  of  properly  graduating 


ACUPRESSURE.  99 

the  compression  to  the  needs  of  the  case,  and  the  minimum  amount  of 
disturbance  which  it  inflicts  upon  the  adjacent  tissues,  is  employed  with 
great  advantage.  When  prolonged  compression  is  needed,-  or  several 
vessels  require  attention,  other  agents  are  required.  Those  that  are  em- 
ployed are  needles,  forceps,  and  ligatures. 

Acupressure. — Needles  or  pins  may  be  thrust  into  the  tissues  so  as  to 
compress  the  extremity  of  a  bleeding  vessel,  either  by  transfixing  the 
tissues  when  in  a  state  of  tension,  and  securing  pressure  upon  the  vessel 
against  the  needle  by  the  force  of  the  elastic  recoil  of  the  tissues,  or  by 
affording  a  solid  substance  against  which  pressure  can  be  made  by  other 
agents. 

The  attraction  of  general  attention  to  the  use  of  acupressure  is  due  to 
Simpson,1  of  Edinburgh,  who  advocated  it  as  a  means  of  diminishing  the 
amount  of  dead  tissue  left  in  a  wound,  of  restricting  suppuration,  and  of 
promoting  early  union  in  wounds.  By  the  pressure  of  the  pin  the  vessel 
is  not  lacerated,  nor  the  vitality  of  any  portion  of  it  destroyed,  and  before 
it  can  become  a  cause  of  suppuration  the  pin  may  be  withdrawn  and  the 
wound  left  free  from  the  presence  of  any  foreign  body  as  an  irritant,  or 
mechanical  impediment  to  repair.  The  compression  with  pins  need  not 
be  prolonged  for  more  than  twenty-four  hours  upon  vessels  of  small 
calibre,  nor  upon  Such  vessels  as  the  brachial  or  superficial  femoral  for 
more  than  forty-eight  hours. 

Any  smooth  sharp-pointed  pin  of  sufficient  length  to  transfix  the 
tissues  suffices  for  use  in  the  practice  of  acupressure.  A  large  shawl-pin, 
as  in  Fig.  4,  by  its  smooth,  globular,  glass  head,  stoutness,  length,  and 
smoothness,  answers  perfectly  for  the  purpose. 


FIG.  4. — Acupressure  Pin. 

The  simplest  method  of  applying  acupressure  is  to  pierce  the  tissues  so 
as  to  bring  the  point  of  the  pin  out  on  the  surface  of  the  wound  close  to 
the  side  of  the  bleeding  vessel,  and  then,  having  carried  it  over  the  vessel, 
to  lift  its  head,  so  as  to  depress  strongly  the  point  and  thrust  it  onward 
into  the  tissues,  close  to  the  vessel  on  the  other  side.  (See  Fig.  5.)  The 
force  of  the  pressure  exercised  by  the  pin  thus  applied,  will  depend 

1  Acupressure  ;  a  New  Method  of  Arresting  Surgical  Hemorrhage  Edinburgh  Med- 
ical Journal,  1860,  v. ,  p.  645. 


100 


THE    TREATMENT    OF    WOUNDS. 


upon  the  amount  and  the  elasticity  of  the  tissue  transfixed  by  it,  and  by 
the  resisting  character  of  the  tissue  against  which  the  pressure  is  made. 
It  is  most  effective  when  the  pin  is  carried  through  the  skin,  so  that  the 


FIG.  5.— Simple  Method  of  Applying  Acupressure. 

latter  is  stretched  between  the  points  through  which  the  pin  passes,  and 
when  the  vessel  is  pressed  against  a  bone.  When  the  skin  is  transfixed, 
and  still  the  pressure  is  not  sufficient  to  arrest  the  haemorrhage,  the  con- 
striction can  be  increased  by  throwing  a  ligature  tightly  around  the  pin, 
on  the  outside,  as  in  the  operation  for  harelip.  When  the  tissues  are  lax 
and  do  not  afford  sufficient  counter-pressure,  their  resistance  can  be  in- 
creased by  twisting  them,  and  by  giving  the  pin  different  directions  in  dif- 
ferent parts  of  its  course  as  it  is  inserted.  Two  methods  of  accomplishing 
this  are  illustrated  in  Figs.  6  and  7. 


Flo.  6.— Acupressure  with  Twist  of  Tissue*.    1.  Pin  introduced  parallel  to  vessel.    2.  Pin  rotated  through 
a  quarter-circle  and,  after  having  been  carried  over  vessel,  thrust  into  tissues. 

Other  variations  in  the  method  of  applying  acupressure  may  suggest 
themselves  according  to  the  particular  relations  of  the  bleeding  vessel. 
Forcipressure. — A  bleeding  vessel  may  be  seized  and  compressed  by 


FORCIPRESSURE. 


101 


suitable  forceps,  and  not  only  the  temporary  but  also  the  definitive  arrest 
of  the  bleeding  be  seciired  without  other  agents.  The  distinctive  appel- 
lation of  forcipressure  was  given  to  this  method  by  M.  Verneuil,1  of  Paris, 


i.  2. 

PIG.  7.— Acupressure  with  Twist  of  Tissues.  1.  Pin  introduced  transversely  to  vessel,  its  point  ready  to 
be  thrust  into  tissues  on  opposite  Bide.  2.  Pin  entered  and  reversed,  twisting  tissues  and  compressing 
vessel. 

in  a  communication  made  to  the  Societe  de  Chirurgie  in  1875,  in  which  he 
reports  twelve  observations  of  haemorrhages  which  he  had  repressed  by 
means  of  forceps  left  from  two  to  ten  days  in  the  wound.  The  writings 
and  practice  of  Pean,"  of  Paris,  Koeberle,3  of  Strassburg,  and  of  Spencer 
Wells,4  of  London,  have  served  to  establish  the  value  of  the  practice  and 
to  attract  to  it  the  attention  which  its  merits  deserve.  The  serres-fines 
(Fig.  8)  and  serres-fortes,  or  compressivpincetten "  (Fig.  9)  of  previous  sur- 


FIG.  8.— Serres-flnes. 


FIG.  9. — Scrre-fort;1,  or  Compressivpincette. 


geons,  which  had  been  used  for  the  temporary  compression  of  bleeding 
vessels,  the  elastic  recoil  of  their  branches  when  separated  being  the  force 
relied  upon  for  pressure,  had  been  found  inconvenient  by  reason  of  their 

1  Bulletins  et  Memoires  de  la  Societe  de  Chirurgie.     Noui-elle  Serie.     Tome  i.     1875- 

2  De  la  Forcipressure^  ou  de  V application  des  pinces  d  Fhemostasie  cfdruryicale,  tfaprt* 
Us  lemons profess'es  pendant  Vannie  1874,  par  M.  le  Docteur  Pean.     Deny  &  Exchaquet. 
8vo,  pp.  72.     Paris  :  Germer  Bailliere.    1875. 

8  De  fhemostase  definitive  par  compression  excessive.     8vo,  pp.  56.     Paris :    J.  IS. 
Bailliere  et  Fils.     1877. 

*  Forcipressure  and  the  Use  of  Pressure- Forceps  in  Surgery.     British  Medical 
Journal,  June  21,  1879. 

5  Vidal  (de  Cassis):     Traite   de  Pathologie  cxterne.      Tome  i.,   pp.   71  and  1  (*'.. 
Paris,  1851. 

•  Angelstein :    Ueber  Compressivpincetten  und  ihren   Gebrauch  behitf*  vorlaafif/er 
Blutstillung.     V.  Graefe  &  Walther's  Journal  der  Chirurgie,  xvii.,  p.  161.     Berlin. 
1831. 


102 


THE    TREATMENT    OF    WOUNDS. 


small  size,  and  unreliable  from  the  feebleness  and  variableness  of  their 
elastic  spring.  The  haemostatic  forceps  of  Pean,  Koeberle,  and  Wells  are 
alike  in  substituting  for  the  uncertain  recoil  spring  of  the  old  instruments 
the  force  of  direct  pressure  exerted  through  long  and  strong,  though 
slender,  levers  as  handles,  which  when  closed  are  locked  by  an  automatic 
catch.  Fig.  10  shows  the  model  of  Pean,  from  which  that  of  Koeberle 
does  not  differ  in  any  essential  respect ;  Fig.  11  that  of  Spencer  Wells. 


Fid.  10. — Haemostatic  Forceps  of  Pean. 


Fro.  11. — Hremostatic  Forceps  of  Spencer 
Wells.     %  size. 


In  seizing  a  bleeding  vessel  with  these  forceps  no  effort  need  be  made 
to  exclude  fibres  of  surrounding  tissue  if  the  vessel  be  small 

The  length  of  time  during  which  the  forceps  should  remain  in  place  in 
order  to  secure  permanent  haemostasia  varies  much.  Those  which  have 
been  applied  upon  the  arterioles  of  the  skin,  connective  tissue,  and  mus- 
cles, and  upon  veins,  except  in  case  of  the  great  venous  trunks,  may  usually 
be  removed  in  a  few  minutes  after  their  application.  Forceps  placed  on 
arteries  of  medium  size  may  be  withdrawn  from  six  to  twelve  hours  after 
the  operation.  Upon  the  main  arteries  of  the  limbs,  including  the 


FORCIPRESSURE. 


103 


femoral,  M.  Pean  advises  that  they  be  left  from  two  to  four  days.  In 
operation  wounds  they  find  their  most  valuable  field  by  reason  of  the  time 
and  blood  that  they  economize  through  the  facility  and  certainty  of  their 
immediate  application  to  each  vessel  that  is  wounded.  In  large  operations, 


-Fio.  12.— Hamostatic  Forceps  Applied  (MacCormac). 


as  in  an  amputation  of  the  thigh,  or  the  extirpation  of  a  large  tumor, 
though  many  forceps  may  have  been  applied  and  remain  hanging  from  the 
wound-surfaces,  in  the  majority  the  haemostasia  will  prove  to  have  bcei 
definitive  by  the  time  the  operation  is  completed,  so  that  the  forceps  may 


104  THE   TREATMENT    OF    WOUNDS. 

then  be  •withdrawn  without  need  of  other  means  to  maintain  closure  of  the 
vessel  Fig.  12  shows  the  manner  of  their  use  for  controlling  haemorrhage 
in  the  course  of  operations. 

These  forceps,  when  left  in  wounds,  are  easily  supported  by  the  dress- 
ings so  as  not  to  drag  upon  the  tissues  ;  rarely  do  they  cause  any  distress 
to  the  patient,  who  becomes  aware  of  their  presence  only  when  they  are 
withdrawn.  When  removed  they  should  be  taken  away  one  by  one  with 
care,  and,  as  soon  as  it  shall  have  become  certain  that  the  vessels  which 
they  were  compressing  no  longer  bleed,  the  dressing  should  be  made  as 
usuaL 

The  application  of  such  forceps  upon  tissues  most  prone  to  resent  in- 
terference has  not  been  productive  of  harm. 

In  all  cases  where  the  application  of  a  ligature  is  impracticable  or  unde- 
sirable, forcipressure  may  replace  advantageously  most  of  the  other  means 
available  in  such  cases.  It  may  be  used  so  as  to  shorten  much  the  dura- 
tion and  danger  of  operations,  and,  by  leaving  no  foreign  body  in  the 
wound,  favors  repair  by  first  intention, 

Ligation. — The  last  method  remaining  to  be  noticed  which  is  available 
for  exerting  compression  upon  bleeding  vessels  is  that  of  encircling  it 
with  a  thread  thrown  about  its  exposed  extremity,  and  tying  it  firmly  with 
a  secure  knot.  This  constitutes  ligation.  Though  it  would  seem  that  this 
method  should  have  instinctively  suggested  itself  for  controlling  the  bleed- 
ing from  a  severed  vessel,  and  though  traces  of  a  theoretical  knowledge  of 
it  as  a  possible  means  for  controlling  haemorrhage  are  discernible  in  the 
writings  of  Galen,  Celsus,  Avicenna,  and  Albucasis,  there  is  no  evidence 
that  it  was  ever  practised  until  it  was  used  by  Pare  in  amputations  in  the 
sixteenth  century.1 

1  The  introduction  of  the  practice  of  lighting  bleeding  vessels  marks  the  first  great 
advance  made  in  the  treatment  of  wounds  in  the  history  of  surgery.  During  the 
ages  previous  to  the  time  of  Par5  the  actual  cautery  had  been  the  principal  means  of 
staunching  traumatic  haemorrhage.  Pare  himself  mentions  his  previous  use  of  the 
cautery  as  "  a  thing  very  horrible  and  too  cruel  to  be  mentioned  "  (chose  ires  horrible 
et  cruette  seulement  d  raconter,  bookx.,  chap,  xxvi.),  and,  in  the  same  chapter,  re- 
lates his  own  first  experiment  in  the  use  of  a  ligature  to  close  the  vessels  after  ampu- 
tation of  a  limb,  as  follows:  "Now  I  advise  the  young  surgeon  to  abandon  such 
cruelty  and  inhumanity  in  order  the  rather  to  follow  this  method  of  mine,  with  which 
it  has  pleaded  God  to  acquaint  me  without  my  ever  having  seen  it  done  by  any  one, 
nor  spoken  of,  nor  mentioned,  except  by  Galen,  in  the  fifth  book  of  his  MetJuxl,  where 
he  writes  that  it  is  necessary  to  tie  the  vessels  on  the  side  toward  their  roots,  which 


THE    LIGATURE    OF    PARE.  105 

The  method  of  Par6  was  to  seize  the  vessels  with  suitable  forceps  (a 
thing  not  difficult  to  do— he  says— because  the  blood  can  be  seen  spouting 
from  them),  draw  them  out  from  the  flesh  into  which  they  have  retracted  and 
become  hidden,  and  then  tie  them  with  a  stout  double  thread.  Although 
Pare"  thus  brought  this  procedure  very  nearly  to  the  degree  of  perfection 
that  it  has  now  attained,  the  prejudices  of  his  contemporaries,  and  the 
erroneous  methods  of  practising  it  followed  by  his  pupils,  caused  it  to 
rapidly  fall  into  discredit,  so  that  a  hundred  years  later  the  surgeons  of 
the  Hotel-Dieu  were  still  to  be  found  always  employing  the  cautery  after 
amputations. '  The  supposed  dangers  from  secondary  hemorrhage,  from 
too  rapid  fall  of  the  ligature,  if  applied  directly  to  the  vessel,  caused  Fare's 
most  distinguished  pupil,  Guillemeau,  to  abandon  the  simple  method  of 
his  preceptor  and  to  practise,  instead,  mediate  ligation,  enclosing  a  mass  of 
adjacent  tissue,  together  with  the  vessel,  iii  the  ligature.  The  effect  of 

are  the  liver  and  the  heart,  in  order  to  staunch  the  great  flow  of  blood.  Now,  having 
many  times  made  use  of  this  way  of  serving1  the  veins  and  arteries  in  recent  wounds 
which  bled,  I  thought  that  it  would  be  well  to  do  as  much  in  the  extirpation  of  a 
limb.  Having  conferred  on  this  matter  with  Stephen  de  la  Riviere,  Surgeon  in  Ordi- 
nary to  the  King,  and  with  other  surgeons  from  Paris,  and  having  declared  to  them 
my  opinion  about  this,  they  advised  that  we  should  make  the  experiment  on  the  first 
patient  that  should  be  offered,  the  more  since  we  could  have  the  cauteries  all  ready 
for  use  in  case  the  ligature  should  fail.  This  I  practised  en  the  spot  on  several  with 
very  good  result ;  and  again,  some  days  later,  in  the  person  of  a  postilion  servitor 
from  Brusquet,  named  Pirou  Gaibier,  whose  left  thigh  was  amputated  four  fingers 
above  the  knee  for  an  inflammation  which  had  supervened  upon  a  fracture. 

"  In  conclusion  I  counsel  the  young  surgeon  to  abandon  this  miserable  way  of  burn- 
ing and  roasting  (unless  some  remnants  of  gangrene  compel  it),  admonishing  him  to 
no  longer  say,  'I  have  read  it  in  the  writings  of  the  ancients,  I  have  wished  to  act  in 
accordance  with  the  teachings  of  my  old  fathers  and  masters,  following  whose  prac- 
tice 1  cannot  err.'  This  I  grant,  if  thou  wilt  "isten  to  thy  good  master,  Galen,  in  the 
passage  already  alluded  to,  and  to  those  like  it ;  but  if  thou  wishest  to  stop  with  thy 
father  and  thy  masters  for  authority  for  bad  practice,  being  willing  to  always  con- 
tinue therein,  doing  just  the  same  as  is  usually  done  by  them  in  all  things,  thou  shalt 
render  an  account  for  it  before  God,  and  not  before  thy  father  or  thy  good  masters, 
who  treat  men  after  so  cruel  a  fashion. "—  GJavres  completes  d?  Ambroise  Pare,  tume 
ii.,  p.  230.  Ed.  Malgaigne. 

The  date  at  which  the  adoption  of  the  practice  of  ligation  was  made  by  Pare  is 
fixed  approximately  by  Malgaigue  to  have  been  about  1500,  since  the  edition  of  his 
works  published  in  1552  mentions  only  the  cautery  as  a  means  of  arresting  hemor- 
rhage, and  that  of  1564  contains  for  the  first  time  mention  of  the  ligature. 

1  Manec :   Traite  de  la  Ligature  des  Arteres,  p.  2.     Paris,  1836. 


106  THE    TREATMENT    OF    WOUNDS. 

such  a  procedure  was  to  assist  the  more  surely  in  bringing  the  use  of  the 
ligature  into  disrepute.  Excruciating  pain,  muscular  spasms,  and  violent 
local  inflammations  were  provoked  by  its  use  in  such  a  way,  while  the 
speedy  loosening  of  the  ligature,  as  it  cut  the  interposed  flesh,  in  a  few 
days,  often  determined  a  mortal  haemorrhage.  Eight  out  of  every  ten 
cases  of  amputation  thus  treated  died.  Mediate  ligation  in  its  turn,  there- 
fore, fell  into  discredit,  and  was  either  abandoned  almost  entirely  or  used 
in  combination  with  styptics  and  escharotics.  The  surgical  world  in  the 
early  part  of  the  eighteenth  century  was  employed  in  a  search  for  hsemo- 
static  agents,  but  the  fear  of  a  recurrence  of  the  bleeding  when  the  ligature 
should  become  detached  still  deterred  surgeons  from  its  use  until  the 
powerful  authority  of  Sharpe,1  in  England  (1760),  and  of  Desault,  in 
France  (1780),  restored  it  to  confidence  and  brought  it  again  among  the 
acknowledged  resources  of  wound-treatment. 

Wide  and  flat  ligatures,  their  size  proportioned  to  the  volume  of  the 
vessels,  were  at  first  deemed  Essential,  lest  the  vessel  should  be  too  rapidly 
cut  through.  It  remained  finally  for  the  present  century  to  demonstrate, 
by  the  experiments  of  Jones,2  that  a  small,  round  ligature  was  the  best 
form  to  use  in  all  cases  for  the  arrest  of  hsemorrhage.  The  conclusions  of 
Jones  having  been  accepted  and  put  in  practice  by  Abernethy  and  Astley 
Cooper,  the  stout  thread  of  Pare  was  restored,  and  the  original  method  of 
that  surgeon,  after  a  lapse  of  two  hundred  and  fifty  years,  became  again 
the  rule  of  surgery.  Nevertheless,  it  still  remained  that  the  application  of 
a  ligature,  however  done,  introduced  a  foreign  body  into  a  wound,  and 
hence  was  to  be  deprecated,  on  account  of  the  disturbance  of  the  repair  of 
the  wound  which  it  produced,  both  directly  and  indirectly,  for  its  final 
separation  and  removal  from  the  wound  necessitated  a  process  of  ulcerative 
absorption  of  the  vessel  which  it  constricted. 

The  part  of  the  vessel  beyond  the  ligature,  when  it  is  applied  upon  the 
cut  extremity,  is  also  deprived  of  nutrition,  and,  dying,  must  be  thrown 

1  This  celebrated  surgeon  to  Guy's  Hospital,  in  his  Critical  Enquiry  into  the 
Present  State  of  Surgery,  formally  advocated  the  employment  of  the  ligature  for  the 
arrest  of  haemorrhage  from  wounded  arteries,  in  preference  to  styptics  or  the  cautery, 
on  the  ground  that  ' '  it  was  not  as  yet  universally  practised  amongst  surgeons  residing 
in  the  more  distant  counties  of  our  kingdom." 

3  A  Treatise  on  the  Method  employed  by  Nature  in  suppressing  the  Haemorrhage 
from  Punctured  and  Divided  Arteries,  and  on  the  use  of  Ligatures.  By  J.  F.  D. 
Jones,  M.D.  8vo.  London,  1805. 


THE    LIGATURE.  107 

off  as  a  slough.  Suppuration  is  the  necessary  attendant  of  these  con- 
ditions, and  when,  as  is  usual,  the  ligature  thread  is  left  hanging  from  the 
wound  until  the  knot  has  ulcerated  itself  loose,  there  is  maintained  a  sup- 
purating sinus  throughout  its  track  which  favors  the  development  of 
serious  septic  conditions  in  the  wound. 

Practically  the  evils  resulting  from  these  unfavorable  conditions,  inci- 
dent to  the  use  of  a  ligature,  are  overcome  in  the  great  majority  of  cases 
by  the  natural  reparative  powers  of  the  body,  and  ultimate  healing  is 
secured  after  a  more  or  less  prolonged  period  of  suppuration  and  contest 
with  inflammatory  and  septic  accidents  of  more  or  less  severity. 

On  account  of  the  interference  with  healing  produced  by  the  ligature, 
importance  has  been  given  to  those  substitutes  for  it  which  in  any  degree 
diminish  the  elements  of  disturbance  produced  by  the  means  needed  for 
fulfilling  the  supreme  indication  of  arrest  of  haemorrhage.  It  is  this 
which  has  given  to  acupressure  and  forcipressure,  and  torsion— a  method 
yet  to  be  noticed — their  chief  importance.  No  substitute  for  the  ligature, 
however,  has  been  able  to  obtain  a  permanent  place  in  the  confidence  of 
surgeons,  and  it  will  undoubtedly  always  remain  the  cliief  resource  for 
arresting  haemorrhage  from  vessels  of  any  size.  It  is  simple  and  easy  of 
application,  it  is  certain  as  a  haemostatic,  and  the  materials  fur  it  are  to  be 
found  in  every  place. 

Of  far  greater  importance  than  the  attempts  at  providing  a  substitute 
for  the  ligature  have  been  the  results  of  studies  to  improve  the  ligatures 
themselves,  striving  to  secure  for  the  use  of  the  surgeon  a  material  strong 
and  efficient  for  the  compression  of  the  vessel,  as  long  as  needed,  un irritat- 
ing while  it  is  performing  its  work,  not  hindering  immediate  union,  and, 
finally,  capable  of  spontaneous  absorption  by  the  tissues  in  which  it  has 
been  buried. 

A  thread  of  any  material  which  can  be  tied  with  sufficient  firmness 
and  closeness  to  effectually  strangulate  a  vessel,  may  bo  used  as  a  ligature, 
and  when  the  emergency  presses  there  may  be  110  choice  left  us  to  a  selec- 
tion. For  general  use  silk  thread — round,  smooth,  well  twisted,  uncol- 
ored,  and  sufficiently  strong  to  stand  considerable  traction — has  been  pre- 
ferred. In  order  to  reduce  to  the  minimum  quantity  the  amount  of  tissue 
to  be  removed  by  ulceration,  it  is  important  that  the  thread  be  110  larger 
than  is  necessary  to  give  it  the  strength  required  to  stand  the  strain  put 
upon  it  when  it  is  tied.  For  small  vessels  the  thread  need  not  be  larger 
than  common  sewing-silk ;  for  larger  vessels,  as  the  femoral,  iliac,  or  axil- 


108  THE    TREATMENT    OF   WOUNDS. 

lary  arteries,  a  somewhat  stouter  thread — saddler's  silk — is  needed.  After 
the  ligature  has  been  tied,  it  has  been  customary  to  clip  off  one  end  close 
to  the  knot,  and  to  bring  out  the  other  at  the  nearest  angle  of  the  wound, 
or,  if  that  was  too  remote,  at  any  more  convenient  point,  where  it  has 
been  necessary  to  permit  it  to  remain  until  the  ligature  has  become  disen- 
gaged from  the  vessel  within  by  its  ulcerative  division.  To  accomplish 
this,  a  period  of  from  three  days  to  three  weeks,  according  to  the  size  of 
the  vessel,  has  been  necessary.  The  amount  and  nature  of  any  other  tis- 
sue that  may  have  been  included  in  the  ligature  together  with  the  vessel, 
will  also  influence  the  time  of  its  detachment  With  the  idea  of  lessening 
the  evils  consequent  upon  such  a  prolonged  residence  of  an  irritating 
thread,  Physick,1  of  Philadelphia,  in  1814,  began  to  use  ligatures  made  of 
leather,  with  the  expectation  that  such  animal  material  would  be  less  irri- 
tating, and  would  undergo  softening  and  absorption.  In  the  year  previous, 
1813,  Dr.  Thomas  Young,  of  Edinburgh,  in  his  "  Introduction  to  Medical 
Literature,"  wrote  :  "I  have  often  wished  to  try  ligatures  of  catgut,  which 
might  be  absorbed,"  but  no  record  of  any  such  test  having  been  made  by 
him  is  given. 

After  Physick,  Jameson,  of  Baltimore,  adopted  the  animal  ligature, 
using  buckskin  cut  into  narrow  strips  and  firmly  rolled.  These,  after  nu- 
merous experiments  and  clinical  observations,  he  declared  to  be  decidedly 

1  The  following  is  Physick' s  own  report  of  his  use  of  animal  ligatures  in  a  commu- 
nication by  him  to  The  Eclectic  Repertory,  1816,  vol.  vi.,  p.  389  : 

"  Several  years  ago,  recollecting  how  completely  leather  straps,  spread  with  adhe- 
sive plaster,  and  applied  over  wounds  for  the  purpose  of  keeping  their  Sides  in  con- 
tact,  were  dissolved  by  the  fluids  discharged  from  the  wound,  it  appeared  to  me  that 
ligatures  might  be  made  of  leather,  or  of  some  other  animal  substance,  with  which  the 
sides  of  a  blood-vessel  would  be  compressed  for  a  sufficient  time  to  prevent  hemor- 
rhage ;  that  such  ligatures  would  be  dissolved  after  a  few  days,  and  would  be  evacu- 
ated with  the  discharges  from  the  wound.  Under  this  impression  I  requested  Dr. 
Dorsey  to  try  the  experiment  on  a  horse  by  using  a  ligature  of  buckskin.  This  was 
found  to  answer  every  purpose  and  came  away  in  a  few  days. 

"  Dr.  Dorsey,  in  several  operations  in  which  I  have  assisted,  has  used  ligatures  of 
French  kid,  which  he  finds  stronger  than  any  other  leather.  He  has  it  cut  into  nar- 
row strips,  stretches  them,  and  peels  off  the  colored  polished  surface.  No  hemor- 
rhage has  taken  place  in  any  instance,  and  the  ligatures  are  found  dissolved  at  the 
end  of  two  or  three  days." 

From  this  period — 1816 — he  continued  to  employ  animal  ligatures  almost  exclu- 
sively up  to  the  time  when  he  left  off  operating.  Memoir  of  Physick,  by  Randolph, 
p.  85. 


ANIMAL   LIGATURES.  109 

superior  to  all  other  ligatures,1  and,  before  his  death,  had  applied  them  to 
all  the  accessible  arteries  of  the  body.*  Animal  ligatures  of  various  kinds 
were  occasionally  used  by  other  isolated  surgeons  during  the  fifty  years 
•which  followed  Physick.  Silk-worm-gut  by  McSweeney,  in  1818, 8  and  by 
Fielding,  in  1826  ; 4  catgut,  by  Sir  Astley  Cooper,  and  fibres  from  the 
sinews  of  the  deer,  by  Eve,  of  Nashville,  were  thus  used ;  but  not  until 
1869,  when  Lister  published  the  results  of  his  experiments  with  catgut 
ligatures,6  and  incorporated  them  into  his  method  of  antiseptic  wound- 
treatment,  did  the  full  value,  and  range  of  the  use  to  which  animal 
ligatures  could  be  put  become  generally  recognized.  Equally  with  cat- 
gut the  parallel  strands  of  connective  tissue  which  make  up  the  tendons 
of  different  animals  have  been  found  to  answer  an  excellent  purpose. 
Marcy,"  of  Boston,  praises  those  from  the  moose  or  caribou,  of  Maine, 
as  most  satisfactory.  The  tendon  from  the  back  of  the  buffalo  and  from 
the  whale  answer  equally  well  The  tendon  of  the  tail  of  the  fox-squir- 
rel of  the  Southern  States  gives  fibres  of  much  strength  and  as  fine  as 
silk.  I  have  received  from  Dr.  Marcy  specimens  of  fibres  from  the  tail 
of  the  kangaroo,  which  excel  all  others  in  the  qualities  desired  for  a  liga- 
ture. Though  these  tendinous  ligatures  have  the  advantage  of  being 
much  stronger  than  catgut,  equal  weights  being  used,  and  of  softening 
less  quickly,  yet  properly  prepared  and  seasoned  catgut  may  always  be 
safely  trusted ;  and  since  it  is  a  staple  article  of  commerce,  to  be  had  all 
over  the  world  in  abundance,  comparatively  cheap,  and  easily  prepared 
and  manipulated,  it  has  maintained  itself  as  the  kind  of  animal  cord  best 
adapted  for  general  use  as  a  ligature,  and  hence  requires  more  extended 
notice. 

Catgut  Ligatures. — Catgut  is  the  submucous  cellular  tissue  of  the  intes- 
tines of  young  lambs,  which,  after  having  been  cleansed  in  an  alkaline  bath 
and  bleached  by  sulphurous  acid,  is  twisted  into  a  cord  and  dried.  As  it 

1  Gross:  System  of  Surgery,  1882,  vol.  i.,  p.  657. 

5  Agnew's  Surgery,  1878,  vol.  i.,  p.  173. 

3  Experiments  in  Favor  of  a  New  Substance  for  Tying  Arteries,  and  for  Suture. 
Edinburgh  Medical  and  Surgical  Journal,  1818,  vol.  xiv.,  p.  597. 

4  On  the  Use  of  a  New  Substance  (Silk-worm-gut)  for  Securing  Divided  Arteries. 
Transactions  Medico-Chirurgical  Society,  vol.  ii.,  p.  340.     Edinburgh,  1826. 

6  Observations  on  Ligature  of  Arteries  on  the  Antiseptic  System.     Lancet,  April  3, 
1869. 

6  Animal  Ligatures.     Annals  of  Anatomy  apd  Surgery,  1881,  vol.  iv.,  p.  233. 


110  THE   TREATMENT    OF    WOUKDS. 

comes  from  the  maker  it  is  entirely  unfit  for  use  'as  a  ligature,  for  when 
bathed  in  the  secretions  of  the  wound  it  quickly  becomes  so  soft  and  pulpy 
that  a  knot  will  not  hold.  By  suitable  preparation  or  seasoning,  however, 
its  qualities  may  be  so  altered  that  immersion  in  blood-serum  will  no 
longer  make  it  pulpy,  but  that  it  will  continue  to  retain  its  form  and  te- 
nacity for  a  somewhat  prolonged  period,  during  which  its  removal  is  being 
slowly  accomplished  by  the  gradual  erosion  of  its  surface  by  the  active  tis- 
sue-cells by  which  it  is  surrounded.  Thus  compression  of  the  tied  vessel 
is  insured  throughout  the  "whole  time  that  the  process  of  its  repair  is 
transpiring. 

Experience  has  shown,  also,  that  it  is  possible  to  over-prepare  the  cat- 
gut so  that  it  may  become  too  rigid  and  difficult  of  absorption,  and  may 
provoke  irritation,  and  suppuration  in  the  wound.  The  following  is  the 
method  advised  by  Mr.  Lister  1  for  the  preparation  of  the  gut,  and  which 
he  recommends  as  certain  to  avoid  the  evils  of  over-preparation,  while  it 
obtains  all  the  tenacity  and  durability  needed  to  fit  it  for  a  ligature.  A 
solution  is  to  be  made,  containing,  of 

Chromic  acid 1  paii. 

Water 4,000  parts. 

Carbolic  acid 200  parts. 

As  soon  as  the  ingredients  are  mixed,  enough  of  the  catgut  should  be  im- 
mersed in  it  to  equal  in  weight  the  amount  of  carbolic  acid  used.  The 
gut  should  remain  in  the  solution  for  forty-eight  hours  only,  at  the  end  of 
which  time  it  should  be  removed,  dried,  and  then  kept  for  use  in  carbolic 
oil,  1  to  5.  The  gut  should  be  kept  on  the  stretch,  by  tying  the  ends  of 
each  hank  to  two  fixed  points  in  a  room,  while  it  is  drying,  otherwise  its 
strength  will  be  seriously  impaired  by  an  uncoiling  of  its  twist  while 
drying. 

The  effect  of  a  longer  immersion  in  the  watery  solution  of  carbolic 
acid  would  be  to  "  over-prepare  "  the  gut,  but  after  its  immersion  in  the 
oily  solution  it  keeps  unchanged  for  an  indefinite  time.' 

1  The  Tatsrut  Ligature.     British  Medical  Journal,  February  5,  1881,  p.  183. 

*  In  the  course  of  some  remarks  made  at  a  meeting  of  the  London  Clinical  Society, 
which  are  reported  in  the  Lancet  of  March  18,  1882,  p.  440,  Mr.  Lister  stated  that  he 
had  been  using  with  still  greater  satisfaction  catgut  prepared  by  soaking  it  for  twelve 
hours  in  a  one  per  cent,  solution  of  chromic  acid,  and  then  for  twelve  hours  more  in 
sulphurous  acid  (B.  P.).  Lastly  it  is  dried,  in  which  state  it  may  be  kept,  being  soaked 


CATGUT    LIGATURES.  Hi 

Without  other  application,  age  alone  renders  catgut  less  easily  softened 
by  blood-serum. 

Immersion  of  catgut  in  oil  of  juniper  for  twenty-four  hours,  and  its 
immediate  transfer  to  alcohol,  ninety-five  per  cent  strength,  in  which  it 
should  be  kept  till  needed,  has  been  introduced  by  Kocher,  of  Berne,  as  r. 
reliable  method  of  preparing  catgut.  The  gut,  thus  prepared,  is  very 
agreeable  to  handle,  ties  nicely,  and  is  not  absorbed  too  soon. 

Italian  catgut  is  superior  to  all  others  in  point  of  durability  and  even- 
ness of  texture.  Harp-strings  should  be  chosen  by  pi-eference  ;  No.  0  for 
the  finest  thread  ;  No.  1  for  medium  ;  and  No.  2  for  the  heaviest  size.1 

After  a  catgut  ligature  is  applied,  the  ends  are  to  be  cut  off  short,  and 
the  wound  closed  without  any  further  attention  being  paid  to  the  ligature. 
When  a  properly  prepared  gut  is  used  nothing  more  is  ever  seen  of  the 
ligature.  It  is  mechanically  unirritating  and  physiologically  aseptic,  and 
produces  no  disturbance  in  the  process  of  repair  by  its  presence,  and  is 
ultimately  removed  by  absorption  in  the  course  of  the  tissue  metamor- 
phoses that  are  incident  to  the  normal  life  of  the  tissues  in  which  it  is  em- 
bedded. An  indefinite  number  of  ligatures  may  bo  applied,  according  to 
the  demands  of  speedy  and  perfect  htemostasis,  in  a  wound  without  hinder- 
ing its  union  by  first  intention.  By  its  use  one  of  the  greatest  hinderances 
to  union  by  first  intention  has  been  removed,  and  the  treatment  of  wounds 
greatly  simplified.  The  portion  of  tissue  included  in  the  noose  of  the  liga- 
ture does  not  die,  nor  does  the  external  coat  of  the  included  vessel  become 
divided  or  ulcera'e.  It  is  applicable  in  septic  wounds  as  well  as  in  those 
that  are  kept  aseptic.  It  is  only  a  little  less  easy  to  manage  than  silk. 

When  immersed  in  carbolic  oil  it  improves  with  age,  so  that  it  is 
especially  adapted  to  being  kept  in  stock  by  the  general  practitioner  for 
occasional  use  at  indefinite  intervals." 

Threads  of  aseptic  silk  and  of  metal  have  been  used  for  ligatures,  and 
with  advantage  over  the  ordinary  thread  on  account  of  their  umrritating 
nature.  Their  ends  having  been  cut  off  close,  the  wound  has  been  closed 

lor  a  quarter  of  an  hour  in  a  carbolic  lotion  before  being  used.  Catgut  thus  prepared, 
will  withstand  the  action  of  living  tissues  for  three  weeks,  and  after  prolonged  steep- 
ing in  carbolic  lotion  is  as  strong  as  in  the  dry  state. 

1  These  can  be  procured  in  New  York  from  L.  H.  Keller  &  Co.,  04  Nassau  Street. 

2  The  surgeon  who  does  not  care  to  prepare  the  catvrut  for  himself,  can  procure  it 
in  a  very  convenient  shape,  and  of  reliable  quality,  ready  for  use,  in  various  sizes. 
wound  on  glass  rollers,  and  kept  in  carbolic  oil,  from  C.  Am  Eude,  of  Hoboken,  N.  J. 


112 


THE    TREATMENT    OF    WOUNDS. 


and  the  union  by  first  intention  of  the  wound  secured,  •while  the  ligature 
has  become  encysted.  Such  a  favorable  result,  however,  experience  has 
shown,  cannot  be  relied  upon  with  any  certainty  in  any  given  case,  so  that 
the  use  of  these  agents  in  this  way  has  fallen  into  general  disfavor,  except 
for  purposes  of  ligating  intraperitoneal  vessels,  in  which  case  a  more  cer- 
tain encysting  of  the  thread  can  be  relied  upon,  owing  to  the  nutritive 
peculiarities  of  that  membrane. 

Silk  thread  may  be  made  aseptic  by  boiling  it  for  an  hour  in  a  five  per 
cent  solution  of  carbolic  acid,  and  afterward  preserving  it  for  use  in  a 
fluid  of  similar  strength  ;  or  by  soaking  it  for  two  hours  in  a  one  per  cent 
solution  of  corrosive  sublimate,  and  subsequently  keeping  it  in  a  weaker 
solution  (one-tenth  of  one  per  cent). 

Technique  of  Ligation. — The  bleeding  vessel  must  be  seized  by  a  suit- 
able pair  of  forceps  and  drawn  out  from  the  tissues,  among  which  it  has 


FIG.  13. — Gross-spring  Forceps. 

retracted,  sufficiently  to  permit  it  to  be  isolated  and  to  be  encircled  by  the 
ligature  far  enough  back  from  its  free  end  to  guard  against  danger  of  its 
slipping  off.  The  haemostatic  forceps  (Figs.  10  and  11)  will  probably  have 
already  been  applied,  and  none  better  could  be  secured  to  facilitate  the 
application  of  the  ligature  when  desirable.  It  is  essential  that  whatever 
forceps  are  used  should  hold  the  vessel  firmly,  and  not  be  liable  to  become 
accidentally  displaced,  and  that  it  should  remain  closed  automatically  when 
once  it  has  been  applied.  The  form  shown  in  Fig.  13,  in  which  the  blades 
cross  and  are  kept  shut  by  their  own  spring,  is  an  excellent  model  The 
expanded  shape  of  the  blades  as  they  near  their  points  facilitates  the  slip- 
ping down  of  the  noose  upon  the  vessel  as  the  thread  is  tied,  and  prevents 
the  forceps  from  being  included  in  the  knot 


Fio.  14. — Tcnacnlum. 


A  terwculum  (Fig.  14)  may  sometimes  be  used  instead  of  a  forceps  for 
picking  up  a  vessel  when  it  is  embedded  in  dense  tissues  that  do  not  per- 
mit its  being  readily  drawn  out.  The  sufficient  isolation  of  the  vessel 
from  other  structures  may  be  generally  effected  without  trouble ;  but  this 


MEDIATE    LIGATION. 


113 


may  not  be  practicable  when  the  tissues  have  been  matted  together  by 
previous  inflammation,  or  where  the  natural  density  of  the  tissues  pre- 


FIG.  16. — Ligation  en  matte  (EtmarcA). 


FIG.  15.— Ligation  of  Vessel  in  Dense  Tissue  (MacCormac). 


vents  its  being  drawn  out.  Should  the  vessels  be  brittle  from  disease  of 
their  coats,  it  may  be  best  also  to  tie  up  with  them  a  cushion  of  the  soft 
parts.  To  accomplish  this  a  curved  needle,  armed  with  the  ligature,  may 
be  passed  beneath  the  bleeding  point  through  the  tissues  so  as  to  include 
with  the  vessel  a  small  portion  of  the  adjacent  tissue,  as  in  Fig.  15  ;  a  liga- 
ture thus  tied  cannot  slip,  and  when  catgut  is  used  and  the  wound  is  kept 
aseptic  no  necrosis  of  the  included  portion  will  take  place. 


FIG.  17.— The  Beef-knot  Flo.  18.— The  Surgeon's  Knot. 

Fig.  16  will  suggest  another  method  of  accomplishing  the  same  end. 

The  ligature  should  be  tied  in  a  single  reef-knot  (Fig  17),  in  preference 
8 


114 


THE    TREATMENT    OF    WOUNDS. 


to  the  surgeon's  knot  (Fig.  18)  or  the  common  granny-knot.  It  is  neces- 
sary to  use  no  more  force  in  drawing  the  knot  than  is  required  to  firmly 
and  securely  close  the  vessel,  which  may  best  be  done  by  placing  the  index 


Pio.  19.— Tightening  the  Ligature. 

fingers  upon  the  thread  close  to  the  point  of  application  to  the  vessel 
(Fig.  19)  and  through  them  making  traction. 

In  ligating  the  larger  arteries  the  knot  should  be  drawn  sufficiently 
tight  to  cause  the  internal  and  middle  coats  to  give  way  if  the  common 
silk  ligature  is  used ;  but  this  is  less  necessary,  though  unobjectionable,  if 
the  catgut  is  used.  "When  the  catgut  or  the  aseptic  silk  ligature  is  used, 
the  ends  should  be  cut  off  short,  and  the  knot  abandoned  to  itself ;  when 


Fio.  20.  Pio.  21. 

Fios.  20  and  21.— Laceration  and  Incurvation  of  Internal  Coats  of  an  Artery  from  External  Injury  (Bryant). 
B  B,  plugs  formed  by  incurved  internal  coats. 

the  ordinary  thread  is  used,  one  end  should  be  clipped  off  quite  close  to 
the  knot,  and  the  other  brought  out  of  the  wound. 

MEANS  OF  PLUGGING  THE  VESSELS. — These  include   torsion,  coagulants, 
and  the  actual  cautery. 


TORSION.  115 

Torsion. — When  the  internal  and  middle  coats  of  an  artery  are  lac- 
erated and  separated  from  the  outer  coat,  the  elastic  quality  of  the  middle 
coat  causes  it  to  become  retracted  and  incurved,  and  thus  to  block  up 
more  or  less  completely  the  lumen  of  the  vessel.  (See  Figs.  20  and  21.) 
Arteries  that  are  torn  across,  as  in  lacerated  wounds,  may  be  spontaneously 
closed  to  such  a  degree  by  this  cause  that  no  bleeding  will  take  place  from 
them,  an  entire  limb  being  torn  from  the  body  without  any  haemorrhage 
following. 

This  retraction  and  incurvation  of  the  inner  coats  of  an  artery  may  be 
accomplished  at  will  by  sharply  twisting  the  cut  end  of  the  vessel.  The 
practice  of  this  manoeuvre  upon  a  bleeding  vessel  constitutes  "torsion." 

The  first  systematic  and  intelligent  application  of  torsion  as  a  means  of 
arresting  bleeding  is  to  be  credited  to  the  French  school  of  surgeons  of 
the  early  part  of  the  present  century,  of  whom  Amussat,1  Velpeau,2  and 
Thierry,3  nearly  at  the  same  time  appeared  as  its  advocates,  each  with  a 
peculiar  method  of  his  own.  To  the  elaborate  memoir  of  Amussat,  especial 
mention  is  due  for  the  manner  in  which  it  developed  and  illustrated  the 
principles  on  which  the  practice  is  to  be  based.  Nevertheless  it  has  never 
gained  general  confidence  except  for  the  closure  of  small  arteries.  More 
recently,  however,  it  has  been  warmly  advocated  by  Bryant,  of  London, 
who  says  :4  "  In  a  physiological  point  of  view  there  is  no  method  more 
perfect  at  command  for  the  control  of  haemorrhage  than  that  of  torsion  ; 
because,  unlike  acupressure,  which  uses  one  only  of  Nature's  haemostatic 
processes,  or  the  ligature,  which  is  a  foreign  body  in  a  wound,  and  be- 
comes a  source  of  danger  by  undoing  at  a  later  what  has  been  done  at  an 
earlier  period  of  the  case,  it  utilizes  to  the  utmost  all  the  physiological 
processes  employed  by  Nature  to  prevent  and  arrest  bleeding,  and  places 
the  vessel  in  the  most  favorable  position  for  them  to  take  effect."  To  con- 
tinue to  quote  from  the  same  author  (p.  302)  :  "  When  an  artery  is  closed 
by  what  is  termed  torsion,  the  inner  coats  are  ruptured  (Fig.  22,  B  and 
C),  and  the  outer  (A),  when  not  twisted  off,  closed  by  the  twists  to  which 
it  has  been  subjected.  But  the  inner  coats,  instead  of  being  simply 

1  Seance  de  F  Academic  Royale  de  Medecine,  July  16,  1829.     Archives  Oenerales  de 
Medecine,  1829,  tome  xx.,  p.  606. 

2  Journal  universal  et  hebdomadairede  Medecine  et  de  Chirurgie,  etc.,  1830,  tome  i., 
p.  488. 

s  De  la  Torsion  des  Arteres.     8vo.     Paris,  1829. 
4  Practice  of  Surgery,  p.  306.     Philadelphia,  1879. 


116 


THE   TREATMENT    OF    WOUNDS. 


divided  in  a  linear  manner,  as  occurs  when  the  ligature  is  used,  become 
ruptured,  separated  from  the  outer  coat  and  incurved,  their  divided  ends 
turning  into  the  vessel,  and  in  the  most  perfect  examples  forming  com- 


Fio.  22. — Effects  of  Torsion  npon  an  Artery  (Bryant). 

plete  valves,  not  unlike  the  semilunar  valves  of  the  heart."  As  to  the 
practical  results  of  torsion,  he  says  (p.  307)  :  "  After  nine  years'  experi- 
ence of  the  practice  among  vessels  of  all  sizes  (the  femoral  being  the  lar- 
gest), I  have  had  no  mishap.  I  have  further  observed  that  wounds  have 


Fio.  23.— Torsion  of  Brachfal  Artery  (ErtcfMenf. 

united  more  rapidly  and  kindly — primary  union  being  the  rule  ;  there  has 
been  less  constitutional  disturbance  after  operation,  and  consequently  less 
liability  to  traumatic  fever,  pyaemia,  and  other  complications,  such  as  we 


TORSION. 

are  all  too  familiar  with  in  the  practice  of  surgery.  At  Guy's  Hospital  we 
have  had  two  hundred  consecutive  cases  of  amputation  of  the  thigh,  leg, 
arm,  and  forearm,  in  all  which  the  arteries  had  been  twisted  (one  hundred 
and  ten  of  them  having  been  of  the  femoral  artery)  and  no  case  of  second- 
ary hemorrhage." 

To  apply  torsion  Amussat  recommended  that  the  artery  be  drawn  out 
for  about  half  an  inch  by  one  pair  of  forceps  ;  that  it  then  be  seized  at  ita 
attached  end  by  another  pair  of  forceps  (see  Figs.  23  and  24)  to  steady  and 


PIG.  24. — Torsion  of  an  Artery  (Esmarch). 

hold  it,  while  with  the  first  pair  of  forceps  the  end  be  twisted  off  by  about 
a  dozen  turns.  According  to  Bryant,  the  vessel  need  be  simply  drawn  out, 
as  for  the  application  of  a  ligature,  and  three  or  four  sharp  rotations  of  the 
forceps  made.  In  large  arteries,  such  as  the  femoral,  the  rotation  should 
be  repeated  till  the  sense  of  resistance  has  ceased.  The  ends  should  not 
be  twisted  off.  In  small  arteries  the  number  of  rotations  is  of  no  impor- 
tance, and  their  ends  may  be  twisted  off  or  not,  as  may  be  preferred.  When 
the  vessels  are  atheromatous  or  diseased,  fewer  rotations  of  the  forceps  are 
required,  the  inner  tunics  of  the  vessel  being  so  brittle  as  to  break  up  at 
once  and  incurve. 

Torsion-forceps  should  have  jaws  broad  enough  to  grasp  the  whole 
width  of  the  vessel  which  is  to  be  twisted,  and  their  teeth  should  be  blunt, 
lest  they  cut  through  the  tissue  of  the  vessel  which  they  grasp. 

Forceps  after  the  model  shown  in  Fig.  25,  devised  by  Wight, '  of  Brook- 
lyn, answer  better  the  requirements  of  torsion  than  the  ordinary  artery 
forceps. 

J  Proceedings  of  the  Medical  Society  of  King's  County,  1880,  p.  380. 


118  THE   TREATMENT   OF    WOUNDS. 

Coagulants.—  The  introduction  into  a  wound  of  substances  which  by 
their  combination  with  the  effused  blood  shall  form  a  firm  tenacious  coagu- 
lum  to  act  as  an  efficient  plug  to  the  bleeding  vessels  is  to  be  resorted  to 
only  as  a  last  resource,  when  other  methods  are  inapplicable  or  inefficient. 
Such  reagents  are  irritants,  the  coagula  formed  act  as  foreign  bodies,  and 
their  use  destroys  any  possibility  of  union  by  first  intention.  Whenever 
used  they  are  to  be  combined  with  direct  compression,  if  possible. 
Wounds  involving  spongy  tissues,  and  cavities  or  organs,  such  as  the 
mouth,  nose,  and  uterus,  where  it  is  impracticable  to  ligate  the  bleeding 


Flo.  25. — Wight's  Artery  Forceps. 

vessels,  most  frequently  call  for  the  application  of  coagulants.  Previous 
to  their  application  the  soft  coagula  already  present  should  be  removed, 
the  bleeding  surface  should  be  wiped  as  dry  as  possible,  and  then  a  com- 
press saturated  with  the  reagent  should  be  firmly  pressed  to  the  bottom  of 
the  wound  directly  upon  the  bleeding  orifices.  The  compress  so  applied 
should  then,  if  possible,  be  secured  in  place  by  a  bandage.  Cavities, 
from  the  walls  of  which  haemorrhage  is  taking  place,  should  be  packed 
with  absorbent  plugs  saturated  with  the  reagent.  Of  the  multitude  of 
substances  that  have  been  used  as  coagulants  but  two  deserve  mention, 
the  subsulphate  of  iron  (Monsel's  salt)  and  alum,  both  of  which  are  effec- 
tive antiseptics  as  well  as  coagulants. 

The  subsulphate  of  iron  may  be  used  either  in  powder  or  in  solution. 
A  compress  saturated  with  a  lotion  made  of  the  officinal  liquor  ferri 
subsulphatis,  diluted  from  four  to  six  times  with  water,  is  a  powerful 
haemostatic,  while  it  is  less  irritating  than  the  stronger  solutions.  The 
iron  produces  immediately  a  dense,  firm,  and  tough  coagulum,  that  con- 
tinues to  shrink  and  harden  for  some  time  after  its  formation. 

Alum  is  less  powerful  and  instantaneous  than  the  iron  salt,  but  its 
astringent  and  coagulating  effect  is  great.  It  may  be  applied  in  powder, 
or  in  saturated  solution.  The  powder  enclosed  in  gauze,  so  as  to  form  a 
small  bag,  forms  an  efficient  haemostatic  tampon,  and  is  particularly  suit- 
able for  plugging  mucous  canals. 

The  Cautery. — Iron  heated  to  a  dull  red  heat  was  the  potential  cautery 
of  the  ancients,  which  alone  was  relied  upon  to  control  arterial  hsemor- 


INTERRUPTING   THE    BLOOD-CURRENT.  119 

rhage.  It  is  still  frequently  made  use  of  for  the  control  of  bleeding  from 
deep-seated  vessels,  and  in  the  course  of  operative  procedures  upon  very 
vascular  parts,  as  the  maxillary  bones,  the  tongue,  the  neck,  the  uterus, 
and  the  rectum.  It  is  not  only  a  coagulant  but  a  caustic,  and  destroys 
the  tissues  to  which  it  is  applied,  forming  a  thick  eschar,  which  for  a 
time  effectually  seals  over  the  entire  wound-surface.  When  it  becomes 
detached  as  a  slough  after  a  few  days,  haemorrhage  frequently  recurs  from 
the  ulcerated  vessels.  Care  is  to  be  exercised  not  to  heat  the  cautery-iron 
above  a  dull  red  heat — the  bright  red  or  white  hot  iron  consuming  the 
eschar  and  leaving  the  vessels  unsealed.  In  the  emergency  which  calls  for 
the  cautery,  the  ingenuity  of  the  surgeon  will  extemporize  the  needed 
cauting-iron.  In  the  systematic  arrangements  for  the  prevention  of  haem- 
orrhage by  the  cautery  in  the  course  of  surgical  operations  the  ancient 
cauting-irons,  with  their  furnace  and  bellows,  have  given  place  to  the 
galvano-  and  thermo-cauteries. 

MEANS  OF  INTERRUPTING  THE  BLOOD-CURRENT. — The  force  with  which  the 
blood-current  shall  reach  the  opening  in  a  severed  vessel  may  be  modified 
by  position,  by  compression  of  the  vessel  or  its  parent  trunk  between  the 
wound  and  the  heart,  and  by  the  internal  administration  of  drugs  which 
lessen  the  force  of  the  heart's  contractions.  These  means  are  chiefly 
available  as  temporary  resources  until  means  of  direct  permanent  hsemo- 
stasis  can  be  devised. 

Position. — The  elevation  of  the  limb,  so  as  to  add  the  force  of  gravity 
to  the  obstacles  to  be  overcome  by  the  blood-current,  will  materially 
diminish  the  force  of  the  arterial  supply  to  the  more  distant  parts  of  the 
limb.  It  promotes  also  depletion  of  the  veins.  It  is  a  resource  not  to  be 
overlooked  in  case  of  wounds  of  the  distal  parts  of  the  extremities. 

Compression  of  the  Vessel,  or  its  Parent  Trunk,  between  the  Wound  and 
the  Heart. — This  may  be  accomplished  by  one  or  more  of  the  following 
ways :  Forced  flexion,  digital  compression,  the  tourniquet,  the  elastic  band- 
age, acupressure,  and  ligation. 

Forced  Flexion. — When  the  forearm  is  strongly  flexed  upon  the  arm, 
in  a  muscular  person,  the  brachial  artery,  in  addition  to  being  bent  at  an 
acute  angle,  is  compressed  both  between  the  biceps  and  brachialis  anticus 
muscles  above,  as  they  contract,  and  at  the  angle  of  flexion  by  the  mus- 
cular mass  there  existing,  while  below,  the  first  portions  of  its  two  main 
branches  are  compressed  between  the  contracted  muscles  of  the  forearm. 
Sufficient  compression  may  thus  be  exerted  to  completely  interrupt  the 


120 


THE   TREATMENT    OF   WOUNDS. 


flow  of  blood  through  the  arteries,  and  to  make 'this  an  efficient  means  of 
assisting  in  the  arrest  of  haemorrhage  from  wounds  of  the  distal  parts  of  the 
upper  extremity,  and  particularly  from  wounds  of  the  palmar  arches.1 

Flexion  of  the  leg  upon  the  thigh  has  but  a  very  feeble  effect  upon  the 
arterial  current  in  the  vessels  beyond.  By  placing  a  compress  in  the  ham 
and  practising  flexion  a  greater  interruption  can  be  produced.  By  strongly 
extending  the  foot,  its  dorsal  artery  may  be  compressed  under  the  anterior 
annular  ligament  sufficiently  to  interrupt  the  current  of  blood  through  ii 

Digital  Compression. — When  the  bleeding  is  from  a  vessel  which,  either 
itself  or  its  parent  trunk,  has  in  some  part  of  its  previous  course  passed 
superficially  over  a  bony  surface,  the  pressure  of  the  thumb  or  fingers  may 
be  sufficient  to  compress  it  against  the  bone  powerfully  enough  to  com- 
pletely interrupt  the  current  of  blood  through  ii 


PIG.  26. — Compressing  the  Carotid  Artery  (EsmarcK). 

The  common  carotid  artery  may  thus  be  compressed  against  the  trans- 
verse processes  of  the  cervical  vertebrae  by  the  thumb  thrust  between  the 
larynx  and  the  inner  border  of  the  sterno-cleido-mastoid  muscle  in  such  a 
manner  as  to  make  pressure  downward  and  inward  (Fig.  26).  The  facial, 

1  Adelmann :  Die  gewaltsame  Beugung  der  Extremitaten  als  Stittungsmtttel  bei  arter- 
ieUen  Blutungen  dersdben.  Archivfur  kttnische  Chirurgie,  1869,  Band  xi.,  Heft  2. 

Pnel :  Recherches  anatomiques  et  experimentales  sur  le  mecanisme  de  Vhemostase  par 
diverges  attitudes  particulieres  des  merribres.  Bulletin  et  Memoire  de  la  Societe  de  Clur 
rurgie  de  Pan*,  1882,  tome  viiL,  p.  727. 


COMPRESSION    OF    ARTERIES. 


121 


temporal,  supraorbital,  and  occipital  branches  are  all  easily  compressed  by 
the  finger  of  one  familiar  with  their  positions. 

The  subclavian  artery  may  be  compressed,  as  it  passes  over  the  first  rib 
behind  the  scalenus  anticus  muscle,  by  strong  pressure  made  downward 
and  inward  into  the  fossa  behind  the  clavicle  at  the  outer  border  of  the 
sterno-cleido-mastoid  muscle.  The  unaided  finger  is,  however,  not  strong 
enough  to  maintain  the  requisite  force.  A  door-key,  with  its  handle  wrap- 
ped with  cloth,  is  the  classical  substitute. 


Fid.  27. — Compressing  the  Brachial  Artery  (Eamarch). 

By  raising  the  arm  and  making  pressure  along  the  anterior  fold  of  the 
axilla,  the  axillary  artery  can  be  compressed  against  the  head  of  the  hu- 
merus. 

The  brachial  artery  may  be  easily  compressed  against  the  humerus,  at 
the  centre  of  the  arm,  by  pressure  made  along  the  inner  border  of  the  bi- 
ceps (Fig.  27). 

The  radial  and  ulnar  branches  are  readily  compressed  in  the  lower  tliird 
of  the  forearm. 

The  abdominal  aorta,  when  the  abdominal  walls  are  relaxed  and  the  in- 
testines empty,  particularly  in  thin  subjects,  can  be  compressed  against  the 
vertebrae,  by  pressure  applied  a  little  to  the  left  of  the  middle  line  at  the 


122  THE    TREATMENT    OF    WOUNDS. 

level  of  the  umbilicus.     The  fingers  of  one  hand  should  be  reinforced  by 
those  of  the  other  to  supply  the  requisite  degree  of  pressure. 

The  common  iliac  artery  may  be  compressed  against  the  brim  of  the 
pelvis  by  the  hand  introduced  into  the  rectum,  or  with  a  lever  of  wood 
introduced  according  to  the  method  of  Davy,  of  London  (Fig.  28). 


Pro.  28. — Compression  of  Common  Iliac  Artery  through  the  Rectum  by  Davy's  Lever. 


The  femoral  artery  is  most  securely  compressed,  just  below  Poupart's 
ligament,  against  the  ileo-pectineal  eminence.  It  should  be  made  with  the 
two  thumbs  placed  the  one  upon  the  other  (Fig.  29),  and  the  pressure 
should  be  made  upward  and  backward  beneath  the  ligament  upon  the  ex- 
panse of  the  eminence.  The  thickness  of  the  intervening  parts  makes 
attempts  at  compressing  the  artery  against  the  femur  in  the  middle  third 
of  the  thigh  uncertain. 


COMPRESSION   BY   TOURNIQUETS. 


123 


The  posterior  tibia!  at  the  inner  ankle,  and  the  dorsalis  pedis  upon  the 
dorsum  of  the  loot,  are  readily  compressed  by  the  fingers. 

Tourniquets. — Any  apparatus  by  means  of  which  graduated  pressure 
can  be  made  upon  a  vessel  is  a  tourniquet.  The  original  idea,  as  the 
name  indicates,  involved  a  twisting  or  screwing  contrivance  for  graduating 
the  pressure,  which  is  the  power  employed  in  the  instrument  most  in  use 
at  the  present  day,  the  tourniquet  of  Jean  Louis  Petit  (1674-1760).  This 


FIG.  30.— The  Modern  Tourniquet. 


FIG.  29. — Compressing  the  Femoral  Artery  (Exmarcti). 

instrument  (Fig.  30)  consists  of  two  metal  plates,  the  distance  between 
which  can  be  regulated  by  means  of  a  screw,  and  which  are  connected  by 
a  strong  silk  or  linen  strap,  which  is  meant  to  pass  around  the  limb,  and 
which  is  fastened  by  a  buckle.  In  using  this  instrument  the  lower  plate, 
underneath  which  a  pad  or  a  roll  of  bandage  has  been  placed,  should  be 
applied  exactly  over  the  point  corresponding  to  the  artery  (Fig.  31) ;  the 
strap  that  encircles  the  limb  should  then  be  drawn  quite  tight,  when  the 
screw  is  turned  so  as  to  force  the  pad  down  upon  the  subjacent  vessel 
until  it  ceases  to  pulsate.  The  tourniquet  in  use  before  the  invention  of 
the  instrument  of  Petit  was  a  simple  band  encircling  the  limb  tightly, 


124 


THE    TREATMENT    OF   WOUNDS. 


underneath  which  a  stick  was  thrust,  by  the  twisting  of  which  powerful 
compression  could  be  produced.  The  same  method  is  still  often  adopted 
with  advantage  for  improvising  a  tourniquet  in  cases  of  emergency.  It  is 
frequently  spoken  of  as  the  "Spanish  windlasa"  A  handkerchief  or  band- 
age, or  any  similar  material,  to  encircle  the  limb,  and  a  stick,  or  rod  of  any 
kind,  to  twist  it  with,  being  the  only  essential  things  for  its  construction  ; 
a  knot  in  the  handkerchief  or  a  stone  enfolded  may  serve  as  a  compress  to 
apply  directly  over  the  vessel  to  be  compressed  (Fig.  32).  Another  form 


FIG.  81. — Compression  of  the  Femoral  Ar- 
tery by  Tourniquet  (Affnew). 


FIG.  32. — Improvised  Torsion  Tourniquet  (Esmarch). 


of  improvised  tourniquet,  applicable  to  the  brachial  artery  is  shown  in  Fig. 
33,  in  which  by  means  of  two  sticks,  arranged  as  shown  in  the  figure, 
powerful  pressure  by  leverage  can  be  exercised  on  the  vessel 

The  application  of  a  tourniquet  should  be  discontinued  at  the  earliest 
possible  moment,  on  account  of  the  pain  which  it  produces,  and  the  inter- 
ference with  the  venous  circulation  of  the  parts  beyond,  as  the  result  of 
which  death  of  more  or  less  of  the  limb  may  ensue.  It  is  to  be  regarded 
only  as  a  temporary  expedient,  to  be  substituted  at  the  earliest  practicable 
moment  by  other  means  of  direct  and  permanent  haemostasia 

The  Elastic  Bandage. — If  a  piece  of  india-rubber  tubing  or  bandage 
(Fig.  34)  be  wound  with  strong  traction  several  times  round  a  limb,  and  the 
ends  be  fastened  by  a  knot  or  clasp,  all  the  soft  parts,  and  with  them  the 


COMPRESSION    BY   ELASTIC    COED. 


125 


vessels,  are  so  firmly  compressed  that  not  a  drop  of  blood  can  pass  through. 
The  facility  and  certainty  with  which  the  blood-current  can  be  interrupted 
by  such  an  elastic  band,  has  caused  it  to  replace,  to  a  very  great  extent,  all 
forms  of  tourniquets,  since  attention  was  drawn  to  its  advantages  in  con- 


Fid.  33. — Double-stick  Tourniquet  (Esmat'ch). 

nection  with  the  bloodless  method  of  performing  surgical  operations  de- 
vised by  Esmarch,  of  Kiel. l  If  an  elastic  bandage  be  put  (no  matter  how 
tightly)  only  once  round  a  limb,  the  pressure  will  not  suffice  completely  to 
compress  the  blood-vessels  ;  but  if  it  be  bound  several  times  round  at  the 
same  point,  every  turn  so  increases  the  pressure  that  in  a  short  time  no 
more  blood  can  pass. 


Fro.  34.— Esmarch'a  Elastic  Tube. 


Acupressure. — Those  methods  of  acupressure  may  be  used  to  compress 
a  vessel  in  its  continuity,  so  as  to  interrupt  the  flow  of  blood  through  it,  in 

1  Ueber  Kunsttiche  Blutleere  bet   Operationen.      Volkmann'a  Sammlung  klinitche 
Vortrdge,  No.  58. 


126  THE   TREATMENT   OF   WOUNDS. 

which,  when  the  tissues  are  transfixed  by  the  needle  they  are  so  put  upon 
the  stretch  that  by  their  elasticity  they  press  the  needle  firmly  and  continu- 
ously against  the  vessel,  or  in  which  the  needle,  having  been  thrust  under 
the  vessel,  is  made  the  base  against  which  pressure  is  made  by  thread 
thrown  over  the  included  tissues  and  about  the  projecting  ends  of  the 
needle  as  in  the  harelip  suture.  Acupressure  may  thus  be  substituted 
with  advantage  in  some  cases  for  ligation  of  vessels  in  their  continuity. 

Ligation. — When  direct  ligation  of  a  vessel  is  impracticable  on  account 
of  the  depth  or  inaccessibility  of  the  wound,  or  because  the  necessary  dis- 
turbance of  the  wound,  or  perhaps  its  extensive  enlargement  to  expose  the 
bleeding  vessel,  is  deemed  inexpedient,  ligation  of  the  vessel  in  its  con- 
tinuity above  the  wound,  or  of  its  parent  trunk,  will  control  the  haemor- 
rhage definitively.  Whenever  permanent  interruption  of  the  main  supply 
current  to  a  part  is  necessary,  ligation  is  to  be  performed.  In  the  choice 
of  material  for  the  ligature,  the  same  reasons  exist  for  preferring  the 
aseptic  catgut  cord  which  have  been  stated  in  connection  with  ligation  in 
the  wound. 

Cardiac  Sedatives. — Little  is  to  be  expected  from  the  action  of  remedies 
administered  internally  for  the  immediate  staunching  of  surgical  haemor- 
rhage, but  in  the  after-treatment  they  may  play  a  more  important  role, 
combined  with  other  general  means.  Gross '  makes  the  following  obser- 
vations on  the  use  of  such  means : 

"  Whatever  mode  of  procedure  be  adopted  for  arresting  the  bleeding, 
it  is  an  object  of  primary  importance  to  place  the  affected  part  perfectly  at 
rest,  in  an  easy  and  elevated  position  ;  the  slightest  motion  might  be  inju- 
rious, especially  when  no  ligature  has  been  used,  and  should,  therefore,  be 
sedulously  guarded  against.  Repose  of  the  body  is  equally  necessary  with 
that  of  the  part,  and  it  is  hardly  needful  to  add  that  mental  tranquillity  is 
also  of  the  greatest  moment.  Cardiac  action,  too,  must  be  maintained  in 
the  most  perfect  quietude,  as  any  perturbing  agency  of  this  kind  cannot 
fail  to  favor  a  return  of  the  hemorrhage  and  exhaust  the  system.  With 
this  view  a  full  anodyne  should  be  administered  early  in  the  disease,  the 
dose  being  repeated  from  time  to  time  so  as  to  sustain  the  soothing  influ- 
ence of  the  remedy.  Too  much  stress  cannot  be  laid  upon  the  use  of  opi- 
ates in  the  management  of  arterial  haemorrhage,  and  it  is  surprising  that 
the  remedy  is  not  more  generally  employed  than  it  seems  to  be.  To  allow 

1  System  of  Surgery,  1882,  vol.  i.,  p.  675. 


CONSTITUTIONAL    TREATMENT.  127 

the  heart  to  go  riot,  or  to  move  and  toss  about  tumultuously,  as  it  is  so 
liable  to  do  after  serious  loss  of  blood,  while  every  local  precaution  is 
taken  for  the  suppression  of  the  bleeding,  is  assuredly  a  strange  inconsist- 
ency, and  one  altogether  irreconcilable  with  experience  and  common 
sense.  When  the  bleeding  proceeds  from  a  great  number  of  small  vessels, 
a  restraining  influence  may  be  expected  from  the  administration  of  ergot 
in  full  and  repeated  doses. 

"  When  high  constitutional  excitement  exists,  the  effect  of  the  anodyne 
should  be  aided  by  the  judicious  use  of  aconite  or  veratrum  viride.  When 
the  skin  is  very  hot  and  dry,  a  full  dose  of  Dover's  powder  often  answers 
an  excellent  purpose  in  calming  the  heart's  action. 

"  The  diet  should  be  perfectly  bland,  and  sufficient  in  quantity  to  sup- 
ply the  wants  of  the  body.  To  give  less  might  cause  irritability  of  the 
system ;  to  give  more,  over-stimulation.  The  drink  must  be  cold  and 
acidulated,  and  not  taken  so  freely  as  to  oppress  the  stomach,  as  it  will  be 
sure  to  do  if  the  quantity  is  not  carefully  restricted,  as  the  thirst  is  always 
urgent  after  the  loss  even  of  a  comparatively  small  amount  of  blood. 
Lumps  of  ice,  or  pounded  ice,  held  in  the  mouth,  and  gradually  swallowed, 
often  prove  most  grateful  and  beneficial.  The  air  of  the  apartment  must 
be  kept  perfectly  cool ;  in  short,  every  effort  must  be  made  to  maintain  the 
tranquillity  of  the  circulation." 


CHAPTEK    VII. 
THE  GENERAL  CONDITION  OF  THE  PATIENT. 

Shock — Anaemia — Auto -transfusion — Transfusion — Direct  Transfusion — Defibrination 
of  Blood — Technique  of  Transfusion— Dangers  of  Transfusion — Peritoneal  Trans- 
fusion. 

SHOCK. 

THE  lighter  degrees  of  shock  quickly  and  spontaneously  disappear ;  in 
the  more  severe  cases  the  indications  are  for  stimulation,  free  access  of 
air,  recumbent  posture,  warmth,  and  reassuring  words  if  consciousness  is 
present 

If  the  patient  is  able  to  swallow,  brandy  or  other  alcoholic  stimulants 
should  be  given  in  small  and  frequently  repeated  doses  till  reaction  is 
assured  ;  if  unconscious,  these  should  be  injected  per  rectum  ;  if  the  pros- 
tration is  extreme,  hypodermic  injections  of  brandy,  in  doses  of  from  one- 
half  to  one  drachm,  or  of  ether,  in  doses  of  from  15  to  30  minims  should 
be  administered.  Intravenous  injections  of  from  5  to  10  minims  of  liquor 
ammonise  fortior  may  also  be  resorted  to.  Repeat  the  injections  every  ten 
minutes  till  the  patient  is  able  to  swallow.  If  reaction  is  delayed,  tincture 
of  digitalis,  in  half-drachm  doses,  every  hour,  should  be  substituted. 

Heat  and  friction  to  the  extremities,  hot  cloths  over  the  heart  and 
stomach,  warm  blankets  to  envelop  the  body  are  also  to  be  employed. 

If  the  respiration  fails,  artificial  respiration  is  to  be  practised. 

If  the  shock  is  being  aggravated  or  prolonged  by  the  irritation  of  a 
mangled  limb,  or  the  presence  among  the  tissues  of  a  foreign  body,  or  the 
continuance  of  haemorrhage,  immediate  operative  interference  is  needed  as 
the  less  of  two  evils  ;  in  all  other  cases  operation  should  be  deferred  until 
reaction  is  secured. 

As  reaction  comes  on,  stimulants  are  to  be  replaced  by  supporting  and 
anodyne  measures.  Renewed  evidences  of  prostration  are  again  to  be  met 
by  the  use  of  stimulants. 


AUTO-TRANSFUSION  -  TRANSFUSION. 


ANAEMIA. 

Should  loss  of  blood  have  been  so  great  as  to  cause  the  want  of  the 
blood  to  be  a  source  of  immediate  danger,  auto-transfusion  should  first  he 
performed. 

AUTO-TRANSFUSION  is  done  when  the  blood  is  forced  from  the  extremi- 
ties and  collected  iii  larger  quantities  in  the  vessels  of  the  central  organs. 
It  is  easy  and  expeditious  of  performance,  and  fi*ee  from  the  dangers  and 
difficulties  of  transfusion,  whether  of  blood  or  of  milk,  and  offers  results 
scarcely  inferior  to  those  of  transfusion  itself.  For  its  performance,  after 
the  haemorrhage  has  been  stopped,  the  patient  must  be  placed  with  his 
feet  higher  than  his  head,  in  order  that  the  blood  may  gravitate  toward  the 
heart  and  medulla  oblongata  ;  the  limbs  are  then  to  be  bandaged  firmly, 
beginning  at  their  distal  portions,  preferably  with  rubber  bandages  —  in 
default  of  which,  however,  ordinary  ones  may  be  used  —  so  that  the  limbs 
are  rendered  comparatively  bloodless.  If  the  fainting  is  extreme,  com- 
plete inversion  of  the  body,  holding  him  up  by  both  feet,  is  the  most  effi- 
cient method  of  revivifying  the  exsanguinated  brain,  while  rhythmical 
compression  of  the  thorax  —  artificial  respiration  —  is  the  best  means  of 
stimulating  the  action  of  the  heart  and  lungs. 

TRANSFUSION.  —  When  the  loss  of  blood  has  been  extreme,  and  auto- 
transfusion  is  inadequate  to  insure  permanent  rallying,  the  injection  of  a 
quantity  of  blood  from  a  healthy  person  into  the  veins  of  the  sufferer  is 
demanded.  One  great  advantage  of  the  practice  of  auto-transfusion  is  as 
a  temporary  expedient  to  gain  time  for  the  necessary  preparations  to  be 
made  for  transfusion. 

Although  transfusion  has  been  practised  only  us  a  dernier  report  in  des- 
perate conditions,  the  results  attained  by  it  which  are  recorded  have  been 
very  encouraging.  When  the  operation  has  been  performed  for  injuries 
to  blood-vessels  or  for  the  haemorrhage  resulting  from  them,  the  recoveries 
were  fifty-eight  per  cent.  ;  when  performed  in  consequence  of  post-partum 
hemorrhage,  the  recoveries  were  fifty-six  per  cent.  ' 

The  operation  is  simple,  easy  to  perform,  and  with  careful  attention  to 
certain  details,  is  free  from  danger.  Since  it  is  an  operation  of  emergency, 
those  methods  only  which  are  the  simplest  and  demand  the  least  special 
apparatus  are  worthy  of  consideration  in  connection  with  it.  For  its  per- 

1  Howe  :  Transfusion  of  Blood.     Annals  of  the  Anatomical  and  Surgical  Society, 

1880,  vol.  ii.,  p.  164. 
9 


130  THE   TREATMENT    OF    WOUNDS. 

feet  performance  no  other  apparatus  is  necessary  than  a  funnel,  a  flexible 
tube,  and  a  canula,  and,  in  default  of  these,  an  ordinary  syringe,  if  it  be 
clean,  and  its  nozzle  be  not  too  large  to  pass  into  the  opened  vein,  will 
suffice. 

The  objections  to  the  use  of  the  syringe  are  that  the  repeated  introduc- 
tions of  its  nozzle  into  the  vein  of  the  recipient  are  often  difficult  and  are 
likely  to  be  attended  with  undesirable  violence  to  the  vein  and  the  adja- 
cent tissues,  and  that  the  required  manipulations,  if  prolonged,  involve  ad- 
ditional dangers  of  the  introduction  of  clots  and  of  air.  Still  these  are 
difficulties  that  can  be  surmounted  by  care  and  skill,  and  should  not  be 
permitted  to  stand  in  the  way  of  making  an  attempt  with  the  syringe  if 
better  apparatus  is  not  available. 


Fio.  35. — Apparatus  for  Transfusion. 

When  the  syringe  is  to  be  used,  the  blood  to  be  injected  is  allowed  to 
fall  into  a  tumbler  or  cup  that  stands  in  a  basin  of  warm  water  (100°  F.). 
As  soon  as  about  two  ounces  have  been  drawn,  it  is  sucked  up  into  the 
syringe,  the  nozzle  of  which  is  then  inserted  into  the  previously  exposed 
vein  of  the  patient,  and  the  contents  slowly  and  cautiously  driven  in. 
This  is  repeated  until  the  required  amount  of  blood  has  been  injected. 

If,  however,  a  suitable  funnel,  tube,  and  canula  (Fig.  35)  can  be  pro- 
cured, the  process  of  transfusion  becomes  less  difficult  and  the  result  much 
more  likely  to  be  satisfactory.  The  principle  upon  which  the  efficiency  of 
such  an  apparatus  depends  is  that  of  hydrostatic  pressure.  The  blood  from 
the  donor  is  made  to  flow  directly  into  the  funnel  as  a  receiver,  and  thence  is 
transmitted  through  the  tube  and  the  canula  into  the  vein  of  the  recipient 


DIRECT   TRANSFUSION. 


131 


(see  Fig.  36).  By  elevating  or  lowering  the  funnel  the  force  of  the  injec- 
tion is  increased  or  diminished.  Such  an  injection  is  gradual  and  continu- 
ous, is  little  likely  to  be  embarrassed  by  the  formation  of  coagula,  and  in- 
volves the  minimum  amount  of  time,  of  manipulation,  and  of  violence  to 
the  vein  and  its  sheath.  Previous  to  inserting  the  canula  in  the  opened 
vein,  both  it  and  the  tube  should  be  filled  with  warm  water,  to  which  a  lit- 
tle salt,  or  five  to  ten  drops  of  liquor  ammonise  have  been  added.  As  the 


FIG.  36.— Direct  Transfusion  by  Hydrostatic  Pressure. 

canula  is  being  inserted  some  of  this  fluid  should  be  allowed  to  slowly 
escape,  that  aU  air  may  with  certainty  be  excluded.  The  whole  apparatus 
should  have  been  previously  warmed  by  immersion  in  blood-warm  water. 
This  apparatus  may  be  quickly  extemporized  from  materials  found  in  every 
drug  shop.  The  canula  may  be  made  from  a  bit  of  glass-tubing,  the  heat 
of  an  alcohol-lamp  being  sufficient  to  enable  the  surgeon  to  shape  it  or 
draw  it  down  to  the  necessary  size. 

A  canula  with  a  stopcock  is  a  convenience,  but  even  the  stopcock  may 


132 


THE   TREATMENT    OF    WOUNDS. 


become  a  source  of  embarrassment  by  introducing  an  unevenness  in  the 
interior  of  the  duct  that  might  determine  the  formation  of  coagula  in  the 
passing  blood-current. 

A  pinchcock  made  out  of  stiff  wire,  as  in  Fig.  38,  is  a  desirable  acces- 
sory when  rubber  tubing  is  used,  but  may  readily  be  replaced  by  the 
thumb  and  finger  of  an  assistant. 

Collin,  of  Paris,  has  united  in  one  instrument  (Fig.  37)  a  syringe  and 
a  funnel,  with  a  flexible  tube  and  canula,  which  of  all  the  special  instru- 
ments that  have  been  devised  deserves  the  highest  mention  for  its  sim- 
plicity and  its  adaptability  to  all  the  requirements  of  blood-transfusion. 


Fio.  37. — Collin's  Instrument  for  Transfusion. 

In  this  instrument  the  funnel  acts  as  a  reservoir  for  the  reception  and 
retention  of  the  blood,  which  is  drawn  from  it  by  the  syringe,  and  driven 
thence  through  the  tube  and  canula  into  the  recipient  vein.  The  opening 
to  the  tube  is  guarded  by  a  ball-valve,  which  permits  only  a  heavy  fluid, 
like  blood,  to  enter.  The  entrance  of  air  is  thus  guarded  against.  The 
air  originally  in  the  tube  should  be  first  expelled  by  forcing  some  of  the 
blood  through  it,  immediately  before  inserting  the  canula  into  the  vein. 
The  injection  may  then  be  proceeded  with,  without  fear  of  any  air  becom- 
ing mingled  with  the  fluid  injected. 

When  transfusion  is  to  be  performed,  a  vein  is  uncovered  at  the  bend 
of  the  arm,  or  above  the  inner  ankle,  by  a  free  incision  through  the  over- 
lying skin.  When  the  vein  has  been  clearly  exposed,  its  anterior  wall  is 
to  be  seized  by  a  fine  forceps,  or  a  tenaculum,  and  lifted  up,  while  a  trans- 


TRANSFUSION. 


133 


verse  incision  is  made  with  knife  or  scissors  in  the  vein,  extending  through 
about  two-thirds  of  its  wall,  so  as  to  make  a  valvular  opening  (Fig.  38). 
While  the  flap  that  has  been  made  is  still  held  up  by  the  forceps,  the 
canula  is  to  be  introduced.  Judgment  is  necessary  in  the  selection  of  a 
canula,  that  too  large  a  one  be  not  chosen.  As  a  rule,  difficulty  will  be 
experienced  in  introducing  into  the  ve,ins  mentioned  a  canula  of  greater 
diameter  than  three  or  three  and  a  half  millimetres.  No  ligature  is  neces- 


FIG.  38.— Mode  of  Introducing  Canula  into  Vein  (Esmnrch)t 

sary  to  secure  the  cauula.  It  should  simply  be  held  in  place  by  the 
gentle  pressure  of  the  fingers  of  an  assistant,  by  which  also  the  distal  part 
of  the  vein  should  be  compressed  at  the  same  time. 

The  blood  to  be  injected  should  be  obtained,  if  possible,  from  a  young 
and  healthy  person,  and  should  be  drawn  in  a  full  stream  from  the  vein  of 
the  donor,  thus  prolonging  the  period  during  which  it  will  remain  without 
tendency  to  coagulate.  To  secure  this  a  free  opening,  at  least  half  an 
inch  in  extent,  should  be  made  in  the  vein  selected,  which  will  generally  be, 
as  for  ordinary  venesection,  either  the  rnedian,»c£phalic,  or  basilic  veins. 


134  THE    TREATMENT    OP    WOUNDS. 

The  blood  may  be  used  as  drawn,  or  may  be  defibriiiated  before  using. 
Defibrination  has  as  its  object  the  prevention  of  dangers  from  coagulation 
of  the  blood.  It  has  been  established,  particularly  by  the  researches  of 
Panum,  of  Copenhagen,  that  blood  deprived  of  its  fibrine  and  exposed  to 
the  air  for  some  time  is  not  materially  deteriorated  for  restorative  pur- 
poses. Defibrination  is  accomplished  by  drawing  the  blood  into  a  clean 
vessel,  and  whipping  it,  until  deprived  of  its  fibrine,  with  broom  wisps, 
those  from  a  new  broom,  thoroughly  cleansed  before  using,  only  should 
be  used.  A  bundle  of  twigs  or  glass  rods,  or  a  fork,  may  also  be  used. 
The  fluid  remaining  should  then  be  strained  through  a  clean,  thick  linen 
cloth,  then  again  whipped,  and  again  filtered  through  clean  white  satin, 
the  dressing  of  which  has  been  previously  removed  by  washing  in  distilled 
water.1  The  filtered  blood  flows  into  a  clean,  dry  glass  vessel,  which  is 
placed  in  warm  water  at  104°  F.,  and  remains  there  till  it  is  required  for 
use.  Whipped  blood  can  be  kept  for  twenty-four  hours  in  a  well-covered 
vessel,  surrounded  with  ice,  but  before  the  transfusion  it  must  be  heated 
by  placing  it  in  warm  water,  and  must  be  saturated  with  oxygen  by 
repeatedly  drawing  it  in  and  out  of  a  syringe.  Defibrinated  blood  may  be 
transfused  either  by  the  syringe  or  by  hydrostatic  pressure.  Fig.  39 
represents  the  apparatus  for  transfusing  by  hydrostatic  pressure  recom- 
mended by  Esmarch.  It  consists  of  a  graduated  glass  cylinder  which 
holds  from  ten  to  twelve  fluid  ounces  (300  to  400  fluid  grammes),  ending 
below  in  a  rounded  and  perforated  point,  to  which  is  fastened  a  foot  of 
india-rubber  tubing.  In  the  lower  end  of  the  latter  is  put  a  small  per- 
forated connecting  piece  of  vulcanite,  which  accurately  fits  the  connecting 
piece  of  the  canule.  The  calibre  of  these  parts  must  all  be  of  the  same 
diameter,  so  that  there  is  no  interruption  in  the  interior  of  the  entire 
tube  (Fig.  40). 

Into  this  cylinder  is  poured  the  defibrinated  blood  ;  as  soon  as  it  flows 
out  of  the  tube  it  is  closed  immediately  above  the  end-piece  by  a  clip. 
Ail  the  air  is  removed  from  the  tube  by  pressing  and  squeezing  in  an 
upward  direction.  To  prevent  the  blood  from  becoming  cool,  the  hand 
which  holds  the  cylinder  can  press  against  its  outer  surface  a  rubber  bag 
filled  with  hot  water,  as  in  Fig.  39,  or  cloths  wining  out  in  hot  water. 

The  end  of  the  tube  is  then  attached  to  the  connecting  piece  of  the 
canule,  which  has  been  meanwhile  introduced  into  a  suitable  vein  after 

1  Esmarch  :  The  Surgeon's  Handbook,  1878,  p.  1G6. 


INDIRECT   TRANSFUSION. 


135 


having  been  completely  filled  with  the  defibrinated  blood,  or  a  warm 
saline  solution.  The  attachment  having  been  made,  the  glass  cylinder  is 
raised  with  one  hand,  the  patient's  arm  with  the  other,  both  clips  are  re- 


FIG.  39.— Transfusion  of  Defibrinated  Blood  by  Hydrostatic 
Pressure  (Esmarch). 


FIG.  40.— Esmnrch's  Cylinder  and  Tube  for 
Transfusion  of  Defibrinnted  Blood. 


moved,  and  the  column  of  blood  is  seen  to  sink  slowly  in  the  cylinder 
(Fig.  39).  As  soon  as  the  cylinder  is  nearly  empty,  the  tube  is  compressed 
with  the  thumb  and  finger,  and  the  caiiule  is  withdrawn  from  the  vein, 
which  is  then  dressed. 


136 


THE   TREATMENT    OF    WOUNDS. 


The  chief  objection  to  defibrinating  the  blood  is  the  time  occupied  in 
the  necessary  manipulations.  When  the  emergency  calling  for  transfusion 
is  not  urgent,  such  an  objection  does  not  hold.  When,  however,  instant 
action  is  necessary,  the  immediate  use  of  the  blood,  as  it  flows  from  the 
donor's  arm,  is  imperative. 

The  dangers  of  transfusion  are  :  1,  embarrassing  the  enfeebled  heart 
by  too  rapid  a  supply  of  new  fluid  ;  2,  the  injection  of  clots  that  may  form 
emboli  ;  3,  the  entrance  of  air. 

The  first  danger  is  to  be  obviated  by  introducing  the  new  blood  very 
slowly,  and  by  guarding  against  the  transfusion  of  too  great  a  quantity. 
Experience  has  shown  that  the  restorative  effects  of  from  six  to  eight 
ounces  of  new  blood  are  fully  as  marked  as  when  a  larger  quantity  is 


FIG.  41. — Aveling's  Apparatus  in  Use.     A,  B,  assistant's  hands  holding  the  canula  in  position;  C,  D,  opera- 
tor's hands  compressing  the  bulb,  and,  alternately,  the  afferent  and  efferent  tubes. 

transfused.  For  the  purpose  of-  transmitting  the  blood  in  a  more  even  and 
gradual  manner  to  the  heart,  the  method  of  injection  into  an  artery,  as  the 
radial  or  posterior  tibial,  in  the  direction  of  the  arterial  current,  has  been 
practised  (Hueter). 

To  obviate  the  second  danger,  the  interior  of  the  tubes  through  which 
the  blood  passes  in  the  process  of  transfusion,  should  be  as  free  as  possi- 
ble from  irregularities,  such  as  projecting  shoulders,  abrupt  turns,  and  stop- 
cocks ;  the  injection  should  be  made  instantly,  and  in  a  regular  and  con- 
tinuous flow  from  its  beginning  to  its  end.  When  time  allows,  defibrina- 
tion  of  the  blood  may  be  practised. 

The  third  danger  needs  only  to  be  kept  in  mind  to  secure  the  necessary 
cautions  in  the  manipulations  of  the  injecting  apparatus  to  exclude  the  air. 


TRANSFUSION.  137 

Numerous  instruments  other  than  those  here  recommended  have  been 
devised  from  time  to  time.  The  original  apparatus  of  Lower  (1666)  was 
for  direct  transfusion  from  vein  to  vein,  by  means  of  silver  canulse  that 
were  connected  together  by  a  flexible  tube  mfde  from  the  cai'otid  artery  of 
a  horse  or  ox.  Aveliug's  instrument  (Fig.  41)  is  essentially  the  same  thing, 
substituting  a  rubber  tube,  expanded  at  one  point  into  a  bulb,  for  the  ox's 
artery  used  by  Lower.  Theoretically  the  direct  transfusion  of  blood 
from  the  vein  of  the  donor  to  that  of  the  recipient  is  a  more  perfect  oper- 
ation than  the  indirect  method  by  syringe  or  hydrostatic  pressure.  Prac- 
tically, however,  the  latter  method  gives  equally  good  results,  while  it  is 
more  easily  and  certainly  accomplished,  and  places  the  amount  and  rapidity 
of  the  new  blood  supply  under  the  full  control  of  the  surgeon. 

Peritoneal  Transfusion. — The  method  of  transfusion  (so  called)  by 
pouring  defibrinated  blood  into  the  peritoneal  cavity  through  a  canula, 
rubber  tube,  and  funnel,  proposed  by  Ponfinck,1  though  possibly  a  valu- 
able therapeutical  measure  in  cases  of  anaemia  of  a  chronic  nature,  cannot 
take  the  place  of  intra-venous  transfusion  in  cases  of  acute  antenna  from 
rapid  and  excessive  loss  of  blood. 

1  Ueber  ein  einfaches  Verfahren  der  Transfusiun.  beim  Menschen.  Wien  Medi- 
zinisclie  Blatter,  1879,  ii.,  p.  846. 


CHAPTER   YIIL 
THE  CLEANSING  OF  THE  WOUND. 

H&mostasis — Sponging — Purification  of  Sponges — Irrigation — Continuous  Submersion 
— Irrigating  Fluids — Drainage — Natural  Drainage — Artificial  Drainage — Drainage 
Tubes — Absorbable  Tubes  of  Neuber,  of  Macewen — Capillary  Drainage — Catgut 
Drains — Horsehair  Drains — Spun- Glass  Drains — General  Considerations  as  to 
Artificial  Drains — Resume — Primary  Drainage — Secondary  Drainage — Accessory 
Means  of  Wound  Cleanliness — Adjacent  Skin — The  Surgeon  and  his  Assistants — 
Instruments  and  Appliances — Compresses  aod  Protective  Appliances — Purifica- 
tion of  the  Air — Spray  Producers — Cleansing  Septic  Wounds— Curettes — Disin- 
fecting Lotions. 

AFTER  haemorrhage  shall  have  been  arrested,  and  the  general  condition 
of  the  patient  shall  have  received  the  attention  which  it  may  have  required, 
the  next  duty  of  the  surgeon  is  to  proceed  to  the  cleansing  of  the  wound. 
A  full  appreciation  of  the  extent  of  the  requirements  of  wound-cleanliness, 
and  of  the  minute  precautions  necessary  for  their  fulfilment,  is  of  the  ut- 
most importance  in  determining  the  future  course  of  a  wound.  What 
these  requirements  are  have  been  discussed  in  the  chapter  in  the  first  sec- 
tion on  Wound-Cleanliness.  They  should  have  a  controlling  influence  in 
the  choice  of  measures  of  haemostasis.  For  it  is  important  in  securing 
final  heemostasis  that  those  means  only  be  used  which  do  not  themselves 
violate  the  rule  of  cleanliness.  The  first,  and  one  of  the  most  important, 
elements  of  cleansing  a  wound,  indeed — with  the  exceptions  noted  in 
Chapter  IV. — is  the  perfect  arrest  of  bleeding  and  the  careful  removal  of 
effused  blood.  The  masses  of  hardened  coagula  which  stj^tics  leave  be- 
hind in  a  wound,  preventing  union  and  speedily  becoming  irritants,  make 
their  use  a  violation  of  cleanliness,  and  therefore  require  their  rejection. 
Exposure  to  the  air  and  compression  alone,  or  compression  with  the  addi- 
tion of  hot  iodized  lotions,  should  be  relied  on  to  check  capillary  oozing. 
For  controlling  bleeding  from  the  larger  vessels,  unirritating  ligatures, 


PURIFICATION    OF    SPONGES.  139 

whose  ends  can  be  cut  off,  and  the  ligature  itself  be  left  to  be  absorbed  or 
encysted,  should  be  used  whenever  possible.  In  default  of  such  ligatures, 
torsion,  forcipressure,  and  acupressure  may  be  resorted  to,  by  preference, 
in  the  order  named.  The  use  of  the  ordinary  silken  ligature  is  a  violation 
of  every  principle  of  wound-cleanliness,  and  its  employment  is  to  be  advo- 
cated only  when,  in  the  absence  of  other  agents,  the  immediate  necessity 
for  its  use  outweighs  its  later  disadvantages.  In  the  further  prosecution 
of  the  primary  cleansing  of  the  wound,  search  is  to  be  made  for  whatever 
foreign  bodies  or  particles — sand,  dirt,  fragments  of  bone,  pieces  of  cloth- 
ing, of  wood,  of  glass,  of  metal,  etc. — may  have  been  left  in  the  wound. 
These  must,  if  possible,  be  removed  before  the  wound  is  closed.  Foreign 
bodies  of  some  size  may  most  readily  be  removed  by  the  fingers  or  by  forceps, 
but  the  more  minute  particles,  as  well  as  the  effused  blood,  and  the  wound- 
secretions,  require  the  use  of  careful  and  gentle  sponging,  or  free  irrigation. 
Both  in  the  primary  cleansing  of  the  wound  and  in  the  after-dressings, 
a  cardinal  principle  to  be  observed  is  to  abstain  from  all  unnecessary  dis- 
turbance of  the  wound-surfaces.  Minute  care  in  accomplishing  primary 
cleansing  will  make  much  more  simple  the  after-cares.  The  dressing  of 
the  wound  should  be  so  managed  that  its  self-cleansing  should  be  continu- 
ous until  healing  is  complete,  and  all  squeezing  and  mopping  and  forcible 
syringing  should  be  unnecessary. 

SPONGING. 

The  sponge  that  is  to  be  used  upon  a  wounded  surface  should  be  of 
fine  texture,  open  cells,  and  sufficiently  elastic  to  expand  readily  in  the 
hand  after  water  has  been  expressed  from  it.  The  whiteness  is  a  matter 
of  little  amount,  unless  the  bleaching  has  been  carried  so  far  as  to  destroy 
its  texture.  It  must  be  soft  and  pure.  Attention  to  the  character  of  the 
sponges  used  is  one  of  the  minor  details  of  wound-treatment,  which  may, 
however,  make  the  difference  between  success  or  disaster  in  the  result. 
The  sponges  that  are  to  be  obtained  ordinarily  from  druggists  in  this  coun- 
try have  undergone  no  preparation  after  their  importation.  Even  the  finer 
qualities  of  Turkey  sponge  that  are  sold  for  surgical  uses  still  contain 
much  sand,  bits  of  coral  and  small  shells,  and  some  organic  impurities. 
Before  they  are  used,  the  sand  and  particles  of  coral  and  of  shells  that 
may  be  lodged  in  their  interstices  should  be  removed,  first  by  a  thorough 
beating  while  the  sponge  is  dry,  and  then  by  prolonged  and  repeated 
washings  in  tepid  water— hot  water  shrivels  a  sponge  and  spoils  it— until 


140  THE    TREATMENT    OF    WOUNDS. 

the  water  comes  off  clear  and  free  from  sand.  After  they  have  dried,  it 
will  be  found  that  a  new  beating  will  still  dislodge  some  sand.  As  soon 
as  the  sponges  are  sufficiently  freed  from  sand,  they  should  be  placed  in 
a  solution  of  permanganate  of  potassa,  1  to  500,  for  twenty-four  hours. 
Then  they  are  again  washed  in  clear  water,  and  placed  in  a  one  per  cent, 
solution  of  hyposulphite  of  soda,  to  which  is  added  one-fifth  the  amount 
of  an  eight  per  cent,  solution  of  hydrochloric  acid  (fort).  The  sponges 
should  remain  in  this  solution  only  for  a  few  minutes,  until  (in  about 
one-quarter  of  an  hour)  they  have  become  white,  being  constantly  stirred 
with  a  wooden  rod  while  in  the  solution. 

It  will  not  be  well  to  let  them  remain  too  long  in  this  bath,  because 
their  substance  will  become  injured  so  that  they  will  lose  their  elasticity 
and  easily  tear.  Lastly,  they  are  again  washed  until  they  are  entirely 
scentless,  requiring  frequent  changes  in  water  during  two  or  three  days, 
and  immersed  in  a  five  per  cent,  solution  of  carbolic  acid  for  at  least  four- 
teen days  before  being  used. 

After  having  been  used  they  should  be  thoroughly  purified  before  be- 
ing again  used.  For  this  purpose,  after  having  been  washed  in  'water, 
they  should  be  repeatedly  washed  in  a  solution  of  carbonate  of  soda — com- 
mon washing  soda — one  ounce  to  the  quart  of  water,  to  remove  any  blood 
or  matter,  then  with  water  again,  and  then  immersed  as  before  in  the  five 
per  cent,  carbolic  acid  solution. 

In  process  of  time,  a  sponge,  after  frequent  using,  will  become  so 
clogged  with  fibiine,  that  cannot  be  washed  out,  that  it  is  useless.  In  such 
cases  the  sponges  may  be  allowed  to  macerate  in  ordinary  water  for  a 
week  or  two,  until  the  putrefaction  of  the  fibiine  has  softened  it  so  that  it 
is  easily  washed  out.  Cleansing  and  immersion  of  the  sponge  in  five  per 
cent  carbolic  acid  solution,  as  before,  will  again  fit  such  sponges  to  be  used. 

When  sponges  have  been  used  upon  surfaces  manifestly  impure,  or 
about  wounds  to  which  any  suspicion  of  infection  attaches,  they  should  be 
steeped  for  five  minutes,  after  the  preliminary  washing,  in  liquor  sodse 
chlorinatse,  diluted  with  an  equal  part  of  water.  A  longer  steeping  endan- 
gers the  destruction  of  the  sponge  itself  by  the  chlorine. 

By  the  use  of  these  measures  for  purifying  sponges,  they  may  be  used 
repeatedly  and  for  an  indefinite  time.  Without  these  precautions,  the  re- 
peated use  of  a  sponge  is  fraught  with  danger,  as  it  may  be  the  bearer  of 
infection  from  one  wound  to  another. 

Whenever  a  soft  sponge  whose  purity  can  be  relied  on  is  not  accessi- 


IRRIGATION. 

ble,  the  cleansing  of  a  wound  should  be  attempted  by  some  substitute  for 
it,  rather  than  by  using  a  sponge  of  doubtful  character.  Pieces  of  cotton 
cloth,  old,  soft,  and  absorbent,  made  clean  and  pure  at  the  time  of  using, 
may  be  made  to  do  good  service  as  substitutes  for  sponges,  and  are  nearly 
always  available.  Dossils  of  absorbent  cotton— cotton  from  which  all  gross 
impurities  and  fatty  matter  have  been  removed,  and  which  is  now  abun- 
dantly supplied  by  various  makers  in  this  country— make  almost  a  perfect 
substitute  for  sponges.  They  may  be  wrung  out  in  any  antiseptic  liquid 
before  using,  and,  being  thrown  away  as  fast  as  used,  are  not  liable  to  vio- 
late cleanliness  by  a  second  use. 

IRRIGATION. 

The  passage  of  a  gently  flowing  stream  of  water  over  the  wound-sur- 
faces, or  through  its  cavities  and  sinuses,  if  such  exist,  constitutes  irriga- 
tion. It  is  especially  adapted  for  cleansing  the  wound  of  fluids,  and  light 
foreign  matter,  and  loose  bits  of  tissue  of  an}-  kind.  No  complicated  ap- 
paratus is  necessary  for  obtaining  irrigation.  The  stream  that  may  be 
squeezed  from  a  sponge,  or  poured  from  a  basin  or  pitcher,  may  often  an- 
swer every  purpose.  The  stream  produced  by  a  syringe  is  objectionable 
on  account  of  its  fitfulness  and  the  uncertainty  of  the  force  with  which  it 
may  strike  the  wound-surfaces.  The  application  of  the  fountain  prin- 
ciple, whenever  possible,  furnishes  the  most  perfect  stream  for  irrigation. 
Whenever  a  bit  of  rubber  tubing,  and  a  utensil  that  will  hold  water  can  be 
had,  as  a  reservoir,  a  fountain  stream  is  possible.  If  from  the  bottom  of 
the  reservoir  a  tube  project,  upon  which  the  rubber  tubing  can  be  slipped, 
it  will  be  convenient ;  but  if  not,  if  the  rubber  tube  be  passed  over  the  top 
of  the  reservoir,  and  be  made  into  a  siphon,  it  will  answer  just  as  good  a  pur- 
pose. By  elevating  and  lowering  the  reservoir,  the  force  of  the  stream  can  be 
perfectly  graduated,  according  to  the  will  and  judgment  of  the  surgeon  ;  by 
replenishing  the  supply  of  fluid  in  the  reservoir,  as  needed,  the  time  through 
which  the  irrigation  shall  be  continued  may  be  indefinitely  prolonged. 

Li  the  after-progress  of  the  wound,  if  union  by  first  intention  be  not 
secured,  recourse  to  irrigation  for  the  purpose  of  cleansing  it  of  retained 
secretions,  and  of  sloughing  debris,  may  be  necessary.  In  this  respect  it 
largely  supplements  drainage,  and  the  measure  of  its  frequency  and  im- 
portance is  the  measure  of  the  imperfection  of  the  provisions  for  drainage. 
The  aim  should  be,  in  all  cases,  first,  by  irrigation  to  remove  all  foreign,  or 
dead,  or  waste  products  from  a  wound  ;  and  second,  by  drainage  to  prc- 


142  THE    TREATMENT    OF    WOUNDS. 

Tent  their  reaccumulation.  Whenever  adequate  drainage  has  been  imprac- 
ticable, continuous  irrigation  might  become  of  value  in  preventing  accu- 
mulation of  noxious  substances.  The  temperature  of  the  water  used  for 
irrigation  should  always  be  equal  to  that  of  the  blood,  for  a  lower  tem- 
perature exerts  a  depressing  influence  on  the  reparative  energy  of  the 
wound. 

Continuous  submersion  in  warm  and  hot  .water  is  a  form  of  irrigation, 
and  its  favorable  effect,  when  experienced,  is  due  to  the  cleansing  of  the 
wound  which  it  accomplishes,  as  well  as  to  its  influence  in  promoting  reso- 
lution of  inflammatory  complications.  The  value  of  such  submersion  in 
the  treatment,  especially  of  lacerated  and  contused  wounds  of  the  extremi- 
ties, has  been  warmly  praised  in  this  country  by  Drs.  Frank  H.  Hamil- 
ton !  and  David  Prince.1  Dr.  Hamilton  states  that  "  no  treatment  hitherto 
adopted,  under  his  observation,  has  been  attended  with  equally  favorable 
results.  Under  this  plan  the  area  of  acute  inflammation  is  exceedingly 
limited  ;  erysipelatous  inflammation  has  been  almost  uniformly  arrested  or 
restrained,  when  it  has  actually  commenced,  and  it  has  never  originated 
after  submersion ;  gangrene  has,  in  no  instance,  extended  beyond  the 
parts  originally  injured,  and  when  progressing,  it  has,  in  most  cases,  been 
speedily  arrested.  Septicaemia  and  pyaemia  have  not  ensued  in  any  case 
in  which  submersion  has  been  practised  from  the  first  day  of  the  accident 
Purulent  infiltrations  and  consecutive  abscesses  have  been  infrequent,  and 
always  limited  to  the  neighborhood  of  the  parts  injured,  and  of  small  ex- 
tent Traumatic  fever,  usually  present  after  grave  accidents,  when  other 
plans  of  treatment  have  been  pursued,  as  early  as  the  third  or  fourth  day, 
has  seldom  been  present  when  this  plan  has  been  adopted,  and  in  no  case 
has  the  fever  been  intense  or  alarming."  The  favorable  effect  of  submer- 
sion upon  the  progress  of  a  wound,  as  described  by  Dr.  Hamilton,  accord- 
ing to  my  experience,  will  not  be  obtained  when  the  character  of  the 
wound  is  such  that  all  its  recesses  are  not  freely  accessible  to  the  water, 
and  when  the  escape  of  the  wound-discharges  is  impeded.  It  is  the  dilut- 
ing and  cleansing  function  of  the  continuous  irrigation  that  it  accomplishes 
to  which  is  due,  in  great  measure,  the  favorable  results  obtained  ;  thus  the 
hot  water,  though  a  carrier  of  septic  germs,  and  itself  favoring  the  processes 
of  fermentation,  yet,  by  its  agency  in  removing  the  necessary  pabulum  for 
the  development  of  the  ferment,  and  by  diluting  and  washing  away  at 


1  The  Medical  Record,  1874,  p.  249. 

2  Annals  of  Anatomy  and  Surgery,  1882,  vol.  v.,  p.  116. 


DRAINAGE.  143 

once  the  noxious  products  of  whatever  fermentation  does  occur,  is  success- 
ful in  preventing  wound-disturbances.  As  accessory  to  this  antiseptic  in- 
fluence, there  should  not  be  overlooked,  in  estimating  the  rationale  of  the 
benefits  to  be  derived  from  this  mode  of  treatment,  the  favorable  effect 
upon  the  nutrition  of  the  immersed  part,  which  the  warmth  and  protection 
of  the  hot-water  bath  exert. 

In  consequence  of  the  favorable  results  obtained  by  the  use  of  immer- 
sion in  warm  water,  reported  by  Langenbeck,1  of  Berlin,  in  1855,  and  by 
Zeis,2  of  Dresden,  in  1856,  this  method  of  wound-treatment  was  for  many 
years  extensively  used  in  Germany,  but  it  has  now  become  largely  replaced 
in  that  country  by  more  perfect  antiseptic  methods. 

Irrigating  Fluids. — Since  ordinary  water  is  a  common  vehicle  for  septic 
germs,  that  which  is  to  be  used  for  irrigating  wounds  must  be  sterilized 
by  adding  to  it  some  antiseptic  in  sufficient  strength  to  destroy  any  germ- 
life  that  may  chance  to  be  in  it.  Of  the  various  antiseptics  those  that  will 
be  found  most  generally  available  and  reliable  for  this  purpose  are  corro- 
sive sublimate  in  the  proportion  of  1  part  to  2,500  of  water  ;  permanganate 
of  potash,  1  to  100  ;  carbolic  acid,  1  to  40,  and  tincture  of  iodine,  1  to  40. 

DRAINAGE. 

Cleansing  of  the  wound  is  finally  completed  by  providing  means  to 
prevent  the  recurrence  in  the  wound  of  conditions  of  wound-contamina- 
tion. Of  these,  the  first,  and  most  important,  is  the  establishment  of  a 
free,  short,  and  direct  channel,  through  which  the  wound-secretions  may 
freely  and  continuously  flow  away.  The  application  of  the  term  "  drain- 
age "  to  this  portion  of  the  management  of  a  wound  is  happily  appropriate, 
for  the  same  physical  problem  is  present  for  solution  as  that  encountered 
by  the  farmer  who  desires  to  rid  his  land  of  undue  and  hurtful  moisture. 
His  ditches,  canals,  and  drains,  find  their  counterpart  in  the  devices 
adopted  by  the  surgeon  to  rid  wound-cavities  of  accumulating  secretions. 

The  provisions  for  drainage  may  be  divided  into  natural  and  artificial. 
By  natural  being  meant  whatever  arrangement  or  dressing  of  the  wound 
shall  favor  the  escape  of  secretions,  apart  from  the  insertion  of  any  appara- 
tus as  means  of  conduction  ;  by  artificial  being  meant  such  tubes,  setons, 
or  tents,  as  may  be  necessary  to  supplement  or  replace  natural  means. 

NATURAL  DRAINAGE  may  be  secured  in  many  instances.     In  wounds  in 

1  Deutsche  KUnik,  1855,  No.  37.  "  Deutsche  Klinik,  October,  1856. 


144  THE    TREATMENT    OF    WOUNDS. 

which  good  coaptation  of  the  surfaces  has  been  possible,  and  yet  in  which 
reasons  exist  for  expecting  the  production  of  much  secretion,  the  escape 
of  such  secretion  may  often  be  sufficiently  provided  for  by  leaving  open 
the  most  dependent  portion  of  the  wound.  In  other  wounds  in  which 
secretions  have  accumulated  so  as  to  produce  tension,  by  cutting  one  or 
more  sutures  sufficient  gaping  of  the  wound  may  be  permitted  to  answer 
the  needs  of  drainage.  In  yet  others,  the  cutting  6f  all  stitches,  and  the 
unrestricted  separation  of  the  entire  wound-borders  may  be  deemed  best. 
The  "  open  "  method  of  treating  wounds,  which'  has  been  proven  to  possess 
great  merits  in  many  instances,  is  a  method  in  which  thorough  natural 
drainage  is  provided  for,  and  to  this  unquestionably  a  large  share  of  the 
benefits  derived  from  the  method  are  due.  The  results  of  different  forms 
of  the  "  open  "  treatment  show  that  the  chief  thing  of  importance  in  its 
management  is  that  fi-ee  escape  of  secretions  be  not  prevented.  For  the 
purpose  of  securing  this  free  escape  wounds  are  to  be  enlarged  by  free 
incisions,  and  counter-openings  made  whenever  required.  A  form  of 
modified  open  treatment  has  recently  been  practised  and  advocated  b}' 
Professor  Kocher,1  of  Berne,  which  he  calls  the  method  by  "secondary 
suture,"  in  which  natural  drainage  is  resorted  to  for  the  removal  of  the 
bloody  and  serous  oozing  that  occurs  during  the  first  twelve  to  twenty-four 
hours  after  the  occurrence  of  a  wound,  by  leaving  the  wound  open  during 
that  peiiod,  septic  infection  being  prevented  by  the  use  of  a  bismuth  lo- 
tion ;  when  the  farther  secretion  has  in  great  measure  been  arrested,  the 
surfaces  are  brought  together  and  sutured,  without  any  necessity  for  fur- 
ther drainage.  All  wounds  which  admit  of  union  by  first  intention,  Pro- 
fessor Kocher  recommends  to  be  subjected  to  this  method  of  treatment  to 
avoid  recourse  to  artificial  drainage. 

ARTIFICIAL  DRAINAGE  includes  all  methods  in  which  foreign  substances 
are  introduced  into  a  wound  for  the  purpose  of  conducting  away  its  dis- 
charges. These  substances  may  act  by  capillarity,  serving  to  keep  the 
wound-surfaces  apart,  and  permitting  the  outflow  of  liquid  to  take  place 
along  the  interstices  between  their  strands,  or  may  pro-vide  tubes  through 
Avhich  a  free  flow  is  secured.  The  use  of  various  artificial  means  for  drain- 
age is  among  the  ancient  resources  of  surgery.  Guy  de  Chauliac  (1300- 
1370)  taught  that  it  was  necessary  to  place  tents  and  setons  "  in  wounds 

• 

which  you  would  enlarge,  cleanse,  or  from  the  bottom  of  which  you  would 


1  TTeber  die  einfachsten  Mittd  znr  Erzidung  einer  Wutidheilung  durcfi  Verkkbuny 
ohne  Darmrohren.     Volkmanu's  Sammlunci  klinincher  Yortrfir/e,  No.  224. 


DRAINAGE    TUBES.  145 

withdraw  anything,  as  in  deep  wounds  which  have  need  of  counter-open- 
ings, because  of  the  liquor  or  the  liquid  excretion  which  gathers  at  the 
bottom  and  in  its  recesses."  One  can  also  make  use,  he  says,  "of  a  tube 
of  brass  or  of  beaten  silver  that  the  ordure  may  escape  from  it  and  not  be 
retained." 

But  not  until  within  the  present  generation  has  the  full  importance  of 
artificial  means  of  drainage  been  demonstrated  and  its  practice  been  sys- 
tematized. With  the  systematic  practice  of  drainage  the  name  of  Chas- 
saignac  is  associated,  whose  researches  were  published,  in  1859,  in  a  work 
entitled,  Traite  pratique  de  la  suppuration  et  da  drainage.  His  method  con- 
sisted in  traversing  from  top  to  bottom  all  purulent  collections  with  vulcan- 
ized rubber  tubes  pierced  with  holes  along  their  sides.  Ho  demonstrated 
and  fixed  in  surgical  practice  the  importance  of  preventing  the  retention  of 
pus,  and  introduced  a  perfect  method  of  drainage  for  purulent  secretions. 

TUBULAR  DRAINAGE. — Pus  cannot  be  removed  by  capillary  drains ;  its 
thickness  and  tenacity  prevent  its  escape  through  such  channels ;  a  tube 
of  some  kind  or  other  must  be  used  to  secure  its  escape.  The  india-rub- 
ber tubes  introduced  by  Chassaignac,  being  flexible,  unirritating,  easy  to 
manipulate,  nearly  always  attainable,  and  cheap,  continue  to  be  regarded 
as  the  most  universally  applicable  means  of  drainage.  These  tubes  may 
be  obtained  of  varying  diameters,  from  one-eighth  of  an  inch  upward,  and 
of  any  length.  The  original  tubes  of  Chassaignac  were  made  of  black 
rubber,  which  has  been  considered  objectionable  from  the  liability  of  the 
free  sulphur  contained  in  them  to  generate  sulphuretted  hydrogen,  and 
thus  to  produce  disagreeable  smells.  This  objection  has  been  obviated  by 
substituting  red  rubber  for  the  black  rubber  in  making  the  tubes.  When 
they  are  to  be  used  for  drainage  purposes  lateral  openings  should  be  made 
in  them  at  short  intervals,  the  diameter  of  each  hole  being  about  one-third 
of  the  circumference  of  the  tube.  These  openings  can  be  readily  made  as 
needed,  by  simply  bending  the  tube  sharply  on  itself  and  snipping  off  one 
of  the  projecting  corners  at  the  bend  with  a  pair  of  scissors.  (See  Fig.  42.) 

Tubes  of  metal,  as  silver,  aluminium,  or  tin,  and  tubes  of  glass  may  be 
substituted  for  the  rubber  tubes,  when  the  compressible  and  flexible  na- 
ture of  the  latter  is  liable  to  be  the  occasion  of  their  obstruction  by  their 
becoming  bent,  or  from  the  pressure  of  the  tissues  through  which  they 
pass,  or  of  the  dressings  that  may  be  applied. 

A  drainage  tube,  of  whatever  substance  composed,  is  a  foreign  body, 

and  as  long  as  it  remains  in  a  wound  is  liable  to  provoke  disturbance. 
10 


146  THE    TREATMENT    OF    WOUNDS. 

They  should  therefore  be  removed  as  soon  as  the  period  of  profuse  secre- 
tion, which  has  made  their  original  use  necessary,  has  passed  away,  or  as 
soon  as  the  cavity  which  they  were  intended  to  drain  has  become  obliter- 
ated. In  incised  wounds,  a  tube  should  not  be  used  at  all  when  the  two 
surfaces  can  be  brought  accurately  together  and  maintained  in  apposition. 
It  is  only  when  care  in  adjustment,  and  the  use  of  proper  means  for  reten- 
tion and  support  and  compression  prove  to  be  insufficient  to  secure  and 
maintain  accurate  adjustment  of  wound-surfaces  that  the  use  of  a  tube  is 
indicated. 


FIG.  42.— Ordinary  Drainage  Tube. 

The  necessity  for  the  removal  of  the  tube,  or  its  readjustment^  if  its 
continued  use  is  indicated,  may  be  a  source  of  disturbance  to  the  progress 
of  the  wound,  and,  in  any  event,  as  long  as  it  remains  in  the  wound,  more 
frequent  dressing  of •  the  wound,  with  its  attendant  dangers  and  disadvan- 
tages, is  necessitated. 

For  this  reason  a  means  of  drainage  which  should  afford  free  escape 
for  secretions  during  the  first  days,  during  which  they  are  most  copiously 
produced,  and  which  should  then  spontaneously  melt  away  and  be  absorbed 
is  a  desideratum.  Such  a  drainage  tube  would  bring  into  the  treatment 
of  wounds  an  advantage  second  only  to  that  already  gained  in  the  substitu- 
tion of  absorbable  ligatures  for  the  irritating  threads  that  demanded  a  con- 
dition of  ulceration  and  suppuration  to  accomplish  their  removal 

Absorbable  tubes,  made  of  decalcified  bone,  have  been  devised  by  Dr. 
Neuber,1  of  Kiel,  and  used  by  him  as  substitutes  for  the  ordinary  tubes  in 
the  primary  dressing  of  wounds.  These  tubes  are  prepared  from  sound 

1  Ein  Antiseptischer  Dauercerband  nach  grundlicher  BlutstUlung.  ArcJdti  fur 
KKnische  Chirurgie,  xxiv.,  Heft  2;  and  xxv.,  Heft  1. 


ABSORBABLE    DRAINAGE   TUBES.  147 

ox  or  horse  bone,  or  ivory,  by  turning  out  of  them,  in  a  lathe,  cylinders  of 
proper  sizes  and  lengths,  and  converting  these  into  tubes  by  drilling  holes 
through  them.  They  are  then  placed  in  a  mixture  of  one  part  of  hydro- 
chloric acid  and  two  parts  of  water.  After  ten  hours'  immersion  the  earthy 
matter  will  have  almost  completely  dissolved  away,  and  the  tubes,  after 
being  washed  of  the  superfluous  acid  in  five  per  cent  carbolic  solution, 
are  ready  for  use.  Such  tubes  are  absorbed  just  as  catgut  is  absorbed 
or  replaced.  According  to  Neuber,  in  six  or  seven  days  the  drain  will  have 
become  soft  and  pulpy,  and  filled  with  lymph.  After  ten  days  all  traces 
of  it  have  disappeared,  except  whatever  portion  may  have  projected  out- 
side, which  will  be  found  lying  detached  like  a  small  ring  and  quite  un- 
changed. 

Doctor  William  Macewen,  of  Glasgow,  has  demonstrated  the  value  of 
the  hollow  femora  and  tibiae  of  domestic  fowls,  as  substitutes  for  the  ex- 
pensive tubes  drilled  out  of  bone,  according  to  the  method  of  Neuber. 
His  method  of  preparation  is  as  follows : '  The  tibiae  and  femora  are 
scraped — bones  from  fowls  which  have  been  cooked  for  the  table  being 
used — and  steeped  in  hydrochloric  acid  and  water  (1  to  5)  until  they  are 
soft  Their  articular  extremities  are  then  snipped  off  with  a  pair  of  scis- 
sors ;  the  endosteum  is  raised  at  one  end,  and  pushed  through  to  the  other 
extremity,  along  with  its  contents.  They  are  then  reintroduced  into  a 
fresh  solution  of  the  same  strength,  until  they  are  rendered  a  little  more 
pliable  and  soft  than  what  is  ultimately  required  (as  they  afterward  harden 
a  little  by  steeping  in  the  carbolized  solution).  When  thus  prepared,  they 
are  placed  in  a  solution  of  carbolic  acid  in  glycerine — 1  to  10.  They  may 
be  used  at  the  end  of  a  fortnight  from  the  time  of  introduction  into  the 
glycerine  solution.  Holes  may  be  drilled  in  them,  or  clipped  out  with 
scissors.  Tubes  thus  formed  are  semi-transparent,  pliable,  and  elastic, 
capable  of  retaining  for  some  time  their  form  under  the  weight  of  thick 
flaps. 

The  average  duration  of  the  chicken-bone  tubes,  out  of  one  hundred 
carefully  recorded  observations,  was  something  over  eight  days. 

In  using  them,  Macewen  directs  that  they  should  always  be  threaded 
with  horse-hair  to  prevent  their  being  blocked  by  blood-clot,  and  to  help  in 
maintaining  the  calibre  of  the  tube  patent  during  the  first  few  days,  espe- 
cially where  the  dressings  might  exercise  pressure.  After  the  first  few  days 

1  The  Drainage  of  Wounds.     British  Medical  Journal,  February  5,  1881,  p.  186. 


148  THE    TREATMENT    OF    WOUNDS. 

the  hairs,  being  no  longer  of  use,  are  to  be  removed,  and  the  tube  left  per- 
fectly patent  A  similar  practice  of  threading  the  tube  with  hair  when  it 
is  to  be  inserted  into  a  recent  wound  commends  itself  for  adoption  with 
any  kind  of  tube.  The  blocking  up  of  a  tube  with  blood-clot  is  an  acci- 
dent apt  to  occur,  in  which  case  surgeons  have  been  in  the  habit  of 
removing  the  tubes,  cleaning  them  of  clot,  and  reintroducing  them.  But 
as  the  reintroduction  irritates  the  wound,  and,  at  times,  provokes  fresh 
bleeding,  it  is  to  be  deprecated.  This  may  be  obviated  by  threading  them 
with  haii-,  as  described,  which  may  be  removed  as  soon  as  the  danger  of 
clot-formation  has  passed. 

Certain  important  practical  difficulties,  which  have  been  found  to 
oppose  themselves  as  obstacles  to  the  realization  of  the  ideal  advantage 
expected  to  be  derived  from  these  bone  drains  of  Neuber  and  Macewen, 
must  be  noted.  They  are  nicely  to  suffer  untimely  collapse,  and  cease  to 
act  as  drains  from  lack  of  sufficient  hardness  of  their  walls  when  immersed 
in  the  wound-secretions.  The  expedient  of  forestalling  this  accident  by 
stuffing  them  with  horse-hair  to  keep  them  patent  is  simply  the  substitution 
of  a  non-absorbable  drain,  and  defeats  the  special  object — infrequency  of 
dressing — which  the  bone  drains  are  devised  to  answer.  Again,  when  not 
too  soft,  they  may  become  absorbed  before  the  necessity  for  drainage  is 
over,  and  by  their  disappearance  determine  retention  of  secretions.  This 
particularly  is  liable  to  occur  in  wounds  which  have  not  been  preserved 
aseptic,  and  those  in  which  the  discharge  is  profuse — conditions  in  which, 
especially,  perfect  freedom  of  drainage  is  important.  Lastly,  if  the  drain 
should  happen  to  become  surrounded  by  a  coagulum  or  by  devitalized 
tissue  its  absorption  would  be  indefinitely  delayed.  These  uncertainties 
in  the  behavior  of  bone  drains  have  prevented  their  use  from  becoming 
general 

CAPILLARY  DRAINAGE. — The  thin  bloody  serum,  which  constitutes  the 
primary  secretion  poured  out  from  a  wound,  is  capable  of  conduction  to 
the  surface  by  agents  that  exert  upon  it  a  capillary  attraction.  For  such 
a  purpose  those  agents  only  are  to  be  used  which  are  unirritating,  compa- 
ratively non-absorbent,  and  sufficiently  fine  in  texture  that  the  interspaces 
formed  when  they  are  made  into  bundles  shall  be  minute  enough  to  exert 
well-marked  capillary  attraction. 

Catgut,  as  a  means  of  drainage  by  capillarity,  was  introduced  by  Pro- 
fessor Chiene,  of  Edinburgh,  who  used  for  the  purpose  very  fine  catgut 
His  manner  of  using  it,  as  described  by  Cheyne,  in  his  work  on  Antiseptic 


CATGUT    DRAINS. 


149 


Surgery,  is  to  take  a  skein  of  catgut,  containing  say  twenty  threads,  and  tie 
it  at  its  middle  by  a  single  thread  of  the  same  gut  One  end  of  this  thread 
is  passed  through  a  needle  (Fig.  43),  and  by  means  of  this  the  centre  of 
the  skein  is  stitched  to  the  deepest  part  of  the  wound.  The  skein  is  now 
broken  up  into  bundles  of  five  or  six  threads  each.  One  bundle  comes 
out  at  each  angle  of  the  incision,  and  the  other  bundles  at  intervals  be- 
tween the  stitches.  (Fig.  44.) 


FIQ.  43.  Fio.  44. 

Pro.  43. —Catgut  Drain  ready  for  insertion  (Cheyne). 

FIG.  44. — Capillary  Wound  Drainage  by  Catgut  (Cheyne}.  The  bunches  of  catgut  coming  ont  at  in- 
tervals between  the  stitches.  (The  wound  exaggerated  and  the  threads  of  catgut  separated,  in  order  to 
show  the  method  more  clearly.)  The  threads  of  catgut  ought  to  lie  in  close  apposition,  for  it  is  the  intervals 
between  the  threads  which  act  as  capillary  tubes. 

By  distributing  the  threads  over  various  parts  of  the  wound  the  true 
principle  of  drainage  is  carried  out ;  for,  as  pointed  out  by  Professor 
Chiene,  in  draining  a  field  one  does  not  have  one  large  drain  going  from 
one  end  of  the  field  to  another ;  on  the  contrary,  the  field  is  traversed  by 
numerous  small  drains.  And  so  in  this  method  we  have  a  number  of 
small  drains  traversing  the  wound  in  several  directions. 

The  catgut  drain  is  an  absorbable  drain,  and  is  exposed  to  objections 
similar  to  those  found  to  attend  the  absorbable  tubular  drains.  Drainage 
might  be  needed  for  a  longer  period  than  the  few  days  during  which  the 
catgut  strands  could  serve  as  a  drain.  It  swells  rapidly  after  being  put  in, 
and  becomes  less  efficient  as  a  drain.  If  found  inefficient,  and  its  removal 
is  desired  before  it  is  absorbed,  it  is  likely  to  have  become  so  closely  con- 


150  THE    TREATMENT    OF    WOUNDS. 

nected  with  the  neighboring  tissues  that  undesirable  violence  to  them  is 
inflicted  by  its  withdrawal 

Horse-hair  presents  itself  as  an  excellent  agent  for  capillary  drainage. 
It  is  always  available,  and  is  unirritating  arid  non-absorbent.  The  fineness 
of  its  threads  make  the  bundles  made  of  it  capable  of  exerting  a  strong 
attractive  force  on  serous  secretions.  The  credit  of  its  suggestion,  as  a 
drain  in  the  treatment  of  wounds,  is  given  to  Mr.  "White,  of  the  Notting- 
ham General  Infirmary.  Before  being  used,  the  hair  should  be  thoroughly 
washed  in  an  alkaline  solution,  to  purify  it  of  all  foreign  matter  that  may 
have  adhered  to  it,  and  afterwards  preserved  in  a  five  per  cent,  watery  car- 
bolic solution.  "When  used,  it  is  made  into  bundles  of  varying  size,  which 
are  simply  laid  in  the  wound  in  situations  most  suitable  for  drainage.  To 
facilitate  their  management,  MacCormac  gives  the  practical  hint  to  choose 
a  sufficient  number  of  hairs,  according  to  the  number  needed,  double  the 
bundle  upon  itself,  and  after  fastening  them  together  by  a  single  hair 
wound  round  them  in  a  spiral  form,  introduce  the  convex  looped  end  into 
the  wound.  A  successive  removal  of  some  of  the  hairs  from  the  bundle 
may  be  made  from  time  to  time,  as  a  diminution  of  the  size  of  the  drain 
may  be  thought  desirable,  before  it  is  finally  withdrawn. 

Macewen  calls  attention  to  the  increased  efficiency  that  may  be  given 
to  a  horse-hair  drain  by  giving  to  it  a  syphon  action.  He  is  of  the  opinion 
that  when  the  hair  is  cut  off  close  to  the  lips  of  the  wound,  when  these  are 
at  a  higher  level  than  the  interior,  so  that  the  fluid  will  require  to  mount 
up,  it  acts  feebly  as  a  drain.  By  leaving  the  portion  on  the  outside  of  the 
wound  longer  than  that  which  remains  in  the  interior  the  wisp  of  hair  may 
easily  be  formed  into  a  syphon.  The  syphonage  is  inaugurated  by  dipping 
the  wisp  into  a  weak  carbolized  solution  before  introducing  it,  and  sur- 
rounding it  with  moistened  gauze.  The  hairs  should  be  tied  together  at 
their  outer  extremity  also  when  syphonage  is  desired. 

Spun  Glass. — Dr.  Herman  Kiimmell,1  of  the  Hamburg  General  Hospital, 
has  called  attention  to  the  superiority  displayed  by  spun  glass,  as  a  mate- 
rial for  capillary  drainage,  over  any  other  substance.  This  material  con- 
sists of  glass  drawn  out  into  threads  of  great  tenuity,  which  are  perfectly 
flexible  and  elastic,  and  feel  to  the  touch  soft  and  smooth  like  fine  wool  or 
silk.  They  are  susceptible  of  being  woven  into  textile  fabrics  like  vegeta- 
ble and  animal  fibres,  and  can  be  obtained  in  the  shops  in  strands,  even 


1  Ueber  eine  neue  Verbandmethode,  etc.     Archiv  fur  Klinische  Chirurgie,  xxviii, 
Heft  3,  pp.  689-692. 


SPUN-GLASS   DRAINS.  151 

ten  feet  in  length.  The  author  advises  that  the  drains  be  formed  by  braid- 
ing together  three  strands,  each  of  suitable  thickness,  and  that  they  be 
kept  ready  for  use  in  a  one  per  cent,  solution  of  corrosive  sublimate.  The 
smallest-sized  drain  should  be  about  the  thickness  of  a  match,  it  being  un- 
desirable to  have  any  greater  bulk  than  is  required  to  carry  on  the  needed 
capillary  flow. 

With  these  glass  braids,  drainage  can  be  insured  to  a  greater  distance 
without  danger  from  retention,  nor  is  it  necessary  to  shorten  them  by  de- 
grees, as  with  rubber  tubes.  They  take  up  but  little  space,  and  being  flat, 
separate  the  tissues  to  a  minimum  amount.  They  produce  less  irritation 
than  other  substances,  never  provoke  suppuration,  and  when  they  are  re- 
moved immediate  adhesion  of  the  tissue  in  their  track  takes  place,  so  that 
no  fistulse  remain  behind.  They  cannot  kink,  however  great  the  compres- 
sion, and  never  clog.  Incisions  and  counter-incisions  to  facilitate  drainage 
are  unnecessary  when  these  are  used,  for  the  capillary  attraction  exerted 
by  them  acts  as  strongly  vertically  as  when  assisted  by  gravitation.  Pus, 
blood,  and  fluids  containing  much  blood,  are  not  removable  by  these 
drains  any  more  than  by  other  capillary  drains.  The  prolonged  residence 
of  these  drains  in  the  tissues  is  attended  with  the  disadvantage  only  which 
arises  from  the  firmness  with  which  they  may  become  grasped  by  the 
granulation  tissue  which  may  insinuate  itself  into  its  interstices.  Kiim- 
mell  is  in  the  habit  of  leaving  the  first  dressing  undisturbed  for  seven 
days,  except  in  operations  of  special  gravity,  in  which  he  changes  his  dress- 
ing on  the  fourth  or  fifth  day.  In  one  case  in  which  he  left  the  drain 
undisturbed  for  fourteen  days  he  was  able  to  dislodge  it  only  by  the  aid 
of  a  cutting  instrument. 

GENERAL  CONSIDERATIONS  AS  TO  ARTIFICIAL  DRAINS. — "  Drains,  of  what- 
ever character,  should  be  so  placed  as  to  carry  the  secretions  from  the 
deeper  parts  of  the  wound,  as  well  as  from  any  irregularity  or  recess,  by 
the  straightest  and  shortest  road  practicable  to  the  surface.  Many  short 
drains,  rather  than  few  and  long  ones,  are  to  be  preferred.  They  are  of 
the  greatest  importance  during  the  first  forty-eight  hours,  and  in  deep, 
extensive,  and  irregular  wounds.  The  more  powerful  the  antiseptic  solu- 
tion employed,  and  the  more  prolonged  its  employment,  the  greater  will 
be  the  amount  of  after-secretion,  and  the  greater  the  necessity  for  efficient 
drainage.  The  first  dressing  is  often  soaked  with  bloody  serum  in  twenty- 
four  hours,  or  even  much  earlier.  When  it  is  necessary  to  employ  drain- 
age tubes  for  a  considerable  time  they  require  periodical  shortening,  or 


152  THE    TREATMENT    OF    WOUNDS. 

must  be  changed  for  smaller  ones.  On  the  renewal  of  the  dressing  they 
should  never  be  used  for  the  purpose  of  syringing  the  wound,  so  long  as 
it  is  aseptic.  The  tube  should  be  large  in  size,  rather  than  small,  placed 
where  it  cannot  be  compressed,  and  have  no  elbows.  The  best  time  to 
insert  the  drains  is  after  the  sutures  have  been  introduced,  but  are  not  yet 
drawn  tight  Two  tubes,  side  by  side,  often  work  very  well.  The  time 
for  their  removal  depends  on  the  amount  of  secretion.  After  four  to  six 
days  the  channel  in  which  the  drain  lies  becomes  lined  with  plastic  matter, 
and  will  remain  open  for  a  short  time  after  its  removal ;  where  several 
drains  are  present  they  ought  to  be  taken  out,  one  after  the  other,  after  an 
interval 

"  The  tubes  should  vary  in  size  from  that  of  the  little  finger  to  that  of 
a  quilL  The  ends  may  be  cut  transversely  or  obliquely,  so  that  they  may 
always  terminate  flush  with  the  surface,  and  never  project  beyond  it ;  any 
projecting  part  is  pressed  on  by  the  dressings,  and  the  other  extremity 
will  thus  be  forced  upon  and  irritate  the  wound-surface,  and  the  function 
of  the  tube  is  impeded. 

"  Loops  of  carbolized  silk  should  be  inserted  at  one  end,  for  the  pur- 
pose of  fastening  the  tube  to  the  skin.  They  would  otherwise  occasionally 
slip  into  the  wound-cavity,  and  might  become  healed  over,  or  they  might 
escape  externally."  1 

R£SUM£. — The  two  indications  to  be  accomplished  by  drainage  of  a 
wound — to  prevent  the  accumulation  of  ferment  pabulum,  and  to  remove 
fluids  already  the  subject  of  ferment  changes — mean  practically  the  drain- 
age of  serum  and  the  drainage  of  pua  The  first  is  primary  and  preven- 
tive in  its  nature,  the  latter  secondary  and  corrective. 

Primary  Drainage. — Since  the  retention  of  accumulated  serum  within 
a  wound  not  only  acts  as  any  foreign  body  to  prevent  apposition  and  to 
disturb  healing  mechanically,  but  also  is  prone  to  rapidly  become  a  fountain 
of  poison  to  the  wound,  as  ferment  changes  take  place  within  it,  the  prob- 
lem of  its  removal  becomes  a  question  of  primary  importance  in  wound- 
treatment,  and  is  second  to  no  other  involved  in  the  subject  of  wound- 
cleanliness.  The  paramount  importance  of  primary  drainage  is  one  of  the 
most  prominent  points  insisted  upon  by  Mr.  Lister,  to  whose  teachings 
and  practice  its  establishment  in  its  proper  place  in  wound-treatment  is 
due  in  great  measure.  The  use  of  drains,  however,  is  to  be  regarded 

1  MacCormac.     Antiseptic  Surgery. 


SECONDARY    DRAINAGE.  153 

always  as  a  complication,  which,  if  possible,  should  be  avoided,  and  to  be 
adopted  only  when  other  possible  means  for  limiting  the  amount  of  serous 
exudation  and  preventing  its  accumulation  must  be  inefficient.  When 
drains  are  unavoidable,  they  should  be  removed  as  soon  as  possible,  that  is, 
as  soon  as  the  tendency  to  serous  exudation  ceases,  or  the  obliteration  of 
the  cavity  drained  by  them  is  accomplished,  a  period  of  time  varying  usu- 
ally from  one  to  four  days. 

Secondary  Drainage. — The  drainage  of  purulent  fluids  constitutes  what 
I  have  chosen  to  call  secondary  or  corrective  drainage.  For  this  purpose 
capillary  drains  are  inadequate,  and  tubes  must  be  used  if  artificial  drains 
are  required.  This  is  the  form  of  drainage  with  which  the  name  of  Chas- 
saignac  will  always  be  associated.  In  its  use,  the  tube,  of  whatever  mate- 
rial, must  be  removed  from  the  wound  at  each  dressing,  and  washed  with 
a  strong  antiseptic  lotion.  If  this  be  not  done,  portions  of  decomposing 
material  will  remain  inside  the  wound,  entangled  in  the  openings  of  the 
tube,  and  will  become  more  and  more  putrid  and  noxious.  The  tubes 
likewise  afford  a  means  for  irrigating  suppurating  cavities  with  cleansing 
and  antiseptic  lotions.  The  use  of  frequent  irrigations  with  an  antiseptic 
lotion,  combined  with  tubular  drainage  and  free  exposure  to  the  air,  has 
been  systematized  by  Prof.  T.  M.  Markoe,  of  the  New  York  Hospital,  in  a 
method  termed  by  him  "  through  drainage."  '  In  this  method  the  wound 
is  caused  to  be  traversed  by  one  or  more  perforated  rubber  tubes,  the 
number  depending  upon  the  extent  and  complexity  of  the  wound.  When 
the  laceration  of  the  deeper  parts  bring  the  wounds  near  to  the  integument 
upon  the  opposite  side  of  the  limb,  or  at  a  distance  from  the  original  aper- 
ture, counter-openings  are  made  and  the  tube  passed  through  so  as  to 
emerge  at  the  new  opening.  Otherwise  the  tube  is  simply  passed  down 
to  the  bottom  of  the  wound  and  the  distal  end  brought  out  again  at  a  little 
distance  from  the  point  of  entrance.  A  wounded  limb,  thus  traversed,  is 
suspended  from  a  framework,  so  that  it  is  raised  from  the  bed,  and  the 
free  discharge  of  the  drainage  from  the  lower  opening  is  secured.  Four 
times  a  day  a  solution  of  one-fortieth  carbolic  acid  is  thrown  through  the 
drainage  tube  with  an  ordinary  syringe,  and  continued  until  the  fluid  dis- 
charged at  the  lower  opening  is  perfectly  clear.  The  penetration  of  this 
fluid  to  all  the  recesses  of  the  wound  is  desirable,  and  for  this  purpose,  if 
necessary,  the  lower  orifice  of  the  tube  is  to  be  pinched  sometimes  while 

1  "  Through  Drainage"  in  the  Treatment  of  Open  Wounds.  American  Journal  of 
the  Medical  Sciences,  April,  1880,  vol.  Ixxix.,  p.  305. 


154  THE    TREATMENT    OF    WOUNDS. 

the  injection  is  being  made.  Professor  Markoe  adds  that  every  case  thus 
treated,  of  a  large  number  of  severe  injuries  suitable  for  the  treatment, 
chiefly  compound  fractures,  went  through  its  successive  stages  without  in- 
flammation at  any  time  sufficient  to  defeat  repair,  and  that  in  every'  case 
the  result  was  equal  to  the  best  attained  in  the  most  favorable  instances  of 
the  given  traumatism. 

ACCESSORY  MEANS  OF  WOUND-CLEANLINESS. 

Second  only  to  the  means  used  for  cleansing  the  wound-surfaces  them- 
selves, are  to  be  regarded  those  for  cleansing  the  tissues  adjacent  to  the 
wound,  and  for  purifying  all  substances,  such  as  the  hands  of  the  surgeon, 
instruments,  retaining  and  protective  dressings,  and  the  air  itself,  which 
are  brought  in  contact  with  the  wound.  These  require  consideration  in 
this  connection. 

ADJACENT  SKIN.  — All  that  portion  of  the  surrounding  integument  which 
is  to  be  included  with  the  wound  under  the  protective  dressings  must  be 
thoroughly  disinfected.  In  the  case  of  operative  wounds,  inflicted  by  the 
surgeon,  this  disinfection  should  be  done  before  making  the  wound ;  in 
the  case  of  accidental  wounds,  it  should  be  done  before  applying  the 
dressings.  The  skin  should  be  shaven,  and  then  thoroughly  scrubbed  with 
a  flesh-brush  and  with  soap  and  water,  or  even  with  ether,  to  remove  fatty 
matters,  and  finally  well  washed  with  a  penetrating  antiseptic  solution  (car- 
bolic acid,  1  to  20,  or  preferably  corrosive  sublimate,  1  to  1,000),  the  anti- 
septic solution  being  allowed  to  act  for  some  time.  Whenever  the  dress- 
ings are  removed,  the  purification  of  the  surrounding  skin  is  to  be  repeated  ; 
and  in  the  treatment  of  wounds  in  specially  septic  regions,  as  the  axilla  and 
perineo-scrotal  regions,  the  dressings  should  be  renewed  with  more  fre- 
quency than  in  other  regions,  for  the  purpose  of  preventing  auto-infec- 
tion. 

THE  SURGEON  AND  HIS  AssisTANTa — The  hands  of  all  persons  employed 
about  a  wound  should  be  thoroughly  purified.  What  has  already  been 
said  about  the  purification  of  the  patient's  skin  applies  equally  to  the  skin 
of  the  hands  of  those  caring  for  him.  Especial  care  is  to  be  directed  to 
the  folds  of  skin  about  the  nails.  The  nails  must  be  well  pared,  and 
thorough  scrubbing  with  a  nail-brush  employed,  first  using  soap  and  water, 
and  afterwards  an  antiseptic  lotion — carbolic  acid  1  to  40,  or  corrosive  sub- 
limate 1  to  1,000.  As  the  dust  and  dandruff  which  may  be  shaken  from  the 


CLEANSING    OF    WOUND-APPLIANCES.  155 

haii*  of  the  head  or  of  the  beard  of  a  surgeon  as  he  bends  over  a  wound 
may  be  septic,  it  will  not  seem  too  great  a  refinement  of  cleanliness  if  their 
purification  also  be  attended  to  in  cases  where  absolute  asepsis  is  of  es- 
pecial importance.  The  use"  of  a  snugly  fitting  cap  to  confine  the  hair 
commends  itself  as  a  cleanly  procedure  quite  as  meet  for  the  surgeon  who 
makes  or  dresses  a  wound,  as  for  the  cook  who  adopts  such  a  device  to 
prevent  mingling  the  impurities  shed  from  his  hair  from  falling  into  the 
victuals  that  he  prepares.  Close  clipping  of  the  beard,  or  better,  its  entire 
removal,  may  not  be  a  point  too  insignificant  to  be  regarded.  The  condi- 
tion of  his  mouth  and  nasal  passages  is  to  be  regarded  by  a  surgeon  who 
would  protect  the  wounds  he  cares  for  from  contamination  by  his  breath. 
The  clothing  worn  should  also  be  scrutinized.  Clean  white  "  dusters,"  or 
other  easily  cleansed  "  over-all "  covering,  upon  which  no  stains  could  pass 
unnoticed,  should  be  wTorn. 

The  towels  and  napkins  used  for  wiping  the  hands  should  themselves 
be  clean  and  still  damp  with  an  antiseptic  liquid,  out  of  which  they  have 
just  been  wrung.  Care  is  to  be  exercised  that  the  hands,  after  having 
been  in  contact  with  any  non-purified  substance,  be  not  used  about  the 
wound  until  they  have  again  been  purified  by  dipping  them  in  an  antisep- 
tic solution. 

INSTRUMENTS  AND  APPLIANCES. — Even  though  scrupulous  cleanliness,  as 
commonly  understood,  be  observed  with  instruments  and  other  appliances 
used  about  a  wound,  they  may  still  bear  septic  dust,  and  introduce  infec- 
tion into  a  wound.  Surgical  cleanliness  demands,  however,  that  every  in- 
strument be  absolutely  free  from  living  organisms  or  their  germs  when  it 
is  used.  For  this  purpose  instruments  should  be  immersed  in  an  antiseptic 
solution  of  sufficient  strength  (carbolic  acid  1  to  20  the  best ;  corrosive 
sublimate  solutions  corrode  steel  instruments,  and  hence  are  not  avail- 
able) for  some  time  before  being  used.  They  are  not  to  be  merely  dipped 
in  ;  they  must  remain  in  the  lotion  for  some  time  ;  the  whole  instrument 
must  be  immersed,  and  so  arranged  as  to  permit  the  fluid  to  come  in  con- 
tact with  all  its  parts.  An  instrument,  thus  purified,  if  laid  down  on  an 
unpurified  surface  should  be  regarded  as  contaminated,  and  should  not  be 
used  again  until  it  has  been  repurified  by  being  dipped  in  the  antiseptic 
lotion.  The  drains,  the  ligatures,  and  the  sutures  must  each  have  been 
previously  immersed  in  antiseptic  liquids  sufficiently  long  to  have  been 
made  completely  aseptic,  and  must  be  retained  in  an  antiseptic  lotion 
until  the  moment  of  use.  Details  of  the  treatment  needed  to  make  asep- 


156  THE    TREATMENT    OF    WOUNDS. 

tic  the  different  substances  used  for  these  purposes  are  considered  in 
other  connections. 

COMPRESSES  AND  PBOTECTIVE  APPLIANCES. — The  external  dressings  which 
are  applied  for  the  purpose  of  maintaining  apposition  in  a  wound,  of  ex- 
ercising compression  upon  it,  and  of  affording  protection  to  it,  must  sat- 
isfy certain  conditions  of  cleanliness,  if  they  are  not  to  become  agents  of 
harm  rather  than  good  to  the  wounds  to  which  they  may  be  applied. 
While  they  must  be  soft  and  mechanically  unirritating,  and  must  be  capa- 
ble of  absorbing  whatever  secretions  emerge  from  the  wound,  and  thus 
contribute  to  the  efficacy  of  drainage,  they  must  also  themselves  be  free 
from  noxious  organisms ;  and,  finally,  if  they  are  to  answer  the  most  im- 
portant requirement  of  protection,  they  must  be  able  in  turn  to  disinfect 
the  secretions  received  by  them  and  the  air  which  filters  through  them. 
Many  substances  have  been  used  which  more  or  less  perfectly  satisfy  these 
conditions.  Cotton  wool  and  loosely  woven  cotton  cloth  (book-muslin, 
tarlatan,  cheese-cloth,  gauze),  lint,  jute,  turf-mould,  charcoal,  sand,  and 
sawdust  are  the  chief  agents  which  are  in  use  for  wound-dressings  at  the 
present  time.  But  to  fit  them  to  completely  answer  the  requirements  of 
wound-cleanliness  by  acting  as  efficient  protectives  against  the  access  of 
noxious  organisms,  it  is  necessary  that  they  should  each  be  charged  with 
some  special  antiseptic  substance.  This  will  be  considered  at  length  in 
Chapter  X. 

PURIFICATION  OF  THE  AIR. — Means  of  isolation  and  ventilation ;  the 
choice  of  a  room  upon  an  upper  floor  ;  the  observation  of  cleanliness  in  all 
the  surroundings  of  the  wounded  person ;  these  are  the  only  agencies  to 
be  relied  upon  to  purify  the  air  which  must  come  in  contact  with  wound- 
surfaces  while  they  are  exposed.  The  dressings  which  are  applied  to  a 
wound  should  be  of  a  character  to  purify  the  air  which  filters  through 
them  as  long  as  they  are  applied.  Should,  however,  in  any  case,  it  be 
deemed  important  to  endeavor  to  secure  the  possible  additional  purifica- 
tion of  the  air  which  washing  it  by  a  cloud  of  spray  might  produce,  a 
steam  spray-producer  would  be  needed  to  furnish  the  necessary  volume  of 
spray.  The  ordinary  spray  instrument  of  Mr.  Lister  (Fig.  45)  answers  as 
a  model  for  such  instruments.  In  this  instrument  a  current  of  steam  is 
made  to  rush  through  a  horizontal  tube  over  a  minute  orifice  at  the  top  of 
a  more  or  less  vertical  one,  the  lower  end  of  which  is  dipped  in  water,  or 
a  watery  solution  of  the  antiseptic,  if  one  be  used.  In  this  way  a  vacuum 
is  produced  in  the  vertical  tube,  and  the  fluid  at  its  lower  end  rises,  and 


AIR    PURIFICATION.  157 

is  expelled  from  the  upper  orifice  in  the  form  of  spray.  The  fluid  used  by 
Mr.  Lister  for  his  spray  is  a  solution  of  carbolic  acid,  1  to  20.  After  hav- 
ing been  mixed  with  the  steam,  it  is  still  further  reduced  in  strength,  the 
spray  being  estimated  to  contain  the  acid  in  the  proportion  of  between  1 
to  30  and  1  to  35. 


PIG.  45. — The  Ordinary  Steain  Spray-producer  of  Mr.  Lister. 

Steam  spray-producers  of  various  models,  which  differ  from  that  of  Mr. 
Lister  only  in  minor  details,  are  made  by  many  instrument  manufacturers 
in  this  country. 

To  obtain  the  full  benefit  of  a  spray  in  purifying  the  air  of  a  room,  the 
volume  of  the  spray  should  be  large  enough  to  diffuse  it  over  the  whole 
area  of  the  room.  The  use  of  several  instruments  placed  in  different 
parts  of  the  room  would  be  better  than  the  use  of  but  one,  however  large. 
The  spray  should  be  projected  near  the  ceiling,  that  it  might  fall  through 
the  entire  mass  of  air  in  the  room,  and  should  be  continued  for  an  hour 
before  the  exposure  of  the  wound. 

As  the  effect  of  the  spray  is  to  mechanically  precipitate  vipon  the  sur- 
faces upon  which  it  falls  the  floating  dust  of  the  air,  it  should  not  be  per- 
mitted to  fall  directly  upon  a  wound-surface.  While  the  wound  is  ex- 
posed its  use  should  be  suspended,  except  at  a  distance  to  wash  currents 
of  air  as  they  enter  the  room. 

CLEANSING  SEPTIC   WOUNDS. 

If  a  wound  has  been  exposed  for  some  time  and  has  already  become 
ill-smelling,  suppurating,  and  inflamed,  energetic  and  thorough  measures 
for  the  complete  disinf ection  of  the  wound  are  necessary.  Although  such  a 
wound  cannot  always  be  made  aseptic,  the  effort  to  produce  such  a  condi- 
tion should  be  made.  In  such  wounds  it  is  to  be  remembered  that  it  is  not 


158 


THE    TREATMENT    OF    WOUNDS. 


only  the  discharges  and  the  superficial  surfaces  in  which  the  septic  germs 
exist  and  must  be  destroyed,  but  that  these  organisms  have  infiltrated  to  a 
varying  extent  the  subjacent  tissues.  As  a  preliminary  to  any  cleansing 


PIG.  46. — Volkmann's  Sharp  Spoon. 

applications  it  is  important  that  all  wound-cavities  and  recesses  be  freely 
laid  open,  as  far  as  possible.  The  mere  conversion  of  a  penetrating  or 
sinuous  wound-track  into  a  free  superficial  wound,  is  sufficient  of  itself  to 
rapidly  modify  the  intensity  of  its  septicity  and  to  encourage  more  healthy 
granulation  in  its  cavity.  Free  exposure  of  the  wound-recesses  having 
been  done,  all  blood-clot  and  disorganized  tissue  should  be  removed,  with 
any  wound-secretions  that  may  have  been  retained.  Should  an  unhealthy 
granulating  surface  be  exposed,  as  is  the  case  in  many  chronically  suppu- 
rating wounds,  the  soft  granulation-material  should  be  scraped  away  just  as 
has  long  been  the  practice  in  dealing  with  carious  bones,  and  as  is  most 


Fia.  47. — Von  Brans'  Spoon  Curettes. 

systematically  and  perfectly  done  by  dentists  in  the  treatment  of  carious 
teeth.  For  this  purpose  spoon-shaped  curettes,  as  those  of  Volkmann, 
Fig.  46,  or  of  von  Bruns,  Fig.  47,  are  efficient  They  scrape  away  all  the 


CLEANSING    SEPTIC    WOUNDS.  159 

soft  inflammatory  material,  but  are  not  sharp  enough  to  materially  attack 
the  healthy  soft  parts  beneath.  The  finger-nail  of  the  surgeon  in  many 
cases  will  answer  perfectly  the  needs  of  a  curette.  In  addition,  when  tis- 
sues are  evidently  infiltrated  with  septic  matter,  they  should  be  cut  away 
or  scarified  deeply  to  admit  of  the  more  perfect  penetration  of  antiseptic 
applications. 

In  all  irregular  wounds,  and  in  those  opening  into  cavities,  in  which  it 
is  not  practicable  to  freely  lay  the  entire  track  of  the  wound  open,  counter- 
openings  should  be  made  at  suitable  points  to  insure  free  through  irriga- 
tion of  all  the  recesses  of  the  wound  or  cavity. 

After  tins  preliminary  preparation  the  wound  must  be  irrigated  with  a 
strong,  germicidal  lotion.  Every  recess  of  the  wound  must  be  reached  by 
the  disinfecting  fluid.  The  lotion  must  be  used  in  sufficient  quantity  to 
thoroughly  soak  the  tissues.  Success  in  rendering  the  wound  aseptic  will 
depend  on  the  thoroughness  with  which  this  final  disinfection  is  done.  In 
an  open  wound,  under  otherwise  favorable  circumstances,  this  is  usually 
not  very  difficult  to  accomplish  ;  but  when  septic  changes  have  been  going 
on  for  some  time  in  irregular  cavities,  or  in  cases  of  septic  phlegmon  ex- 
tending into  the  intermuscular  spaces,  in  suppuration  of  the  ai'ticulations, 
or  in  severe  compound  fractures,  it  is  always  difficult  (MacCormac). 

Chloride  of  zinc  is  to  be  preferred  as  the  germicide  to  disinfect  septic 
wounds,  because  its  caustic  effect  causes  the  disinfection  produced  by  it  to 
extend  more  deeply  into  the  subjacent  tissues,  and  because  the  protective 
film,  which  its  combination  with  the  albuminoids  of  the  tissues  produces, 
resists  for  so  long  a  time  the  effects  of  any  septic  matters  still  remaining  in 
other  parts  of  the  wound  or  introduced  from  without.  The  eight  per  cent, 
solution  (forty  grains  to  the  ounce  of  water)  should  be  used.  It  may  be 
applied  by  irrigation,  and,  in  addition,  the  wound-cavity  should  be  filled 
with  compresses  soaked  in  the  fluid. 

Carbolic  acid,  by  reason  of  its  volatility  and  its  diffusibility,  may  be 
preferred  for  injecting  irregular  cavities  and  narrow  sinuses.  The  stronger 
solution,  five  per  cent.,  is  to  be  used  until  the  wound  has  been  rendered 
completely  aseptic.  In  the  after-cares  more  dilute  solutions,  whether  of 
the  zinc  or  of  the  acid,  may  be  used.  Throughout  the  future  course  of 
such  a  wound,  greater  care  and  watchfulness  against  the  possible  redevel- 
opment of  septicity  will  be  required  than  would  be  deemed  necessary  in 
the  management  of  a  wound  aseptic  from  the  first. 


CHAPTER  IX. 
APPOSITION  OF  THE  WOUND-SUKFACES. 

Position — Bandaging — Rollers — Compresses — Adhesive  Plaster — Icthyocolla  Plaster — 
Gold-beater's  Skin — Collodion — Application  of  Adhesive  Bandage — Objections  to 
Adhesive  Bandages — Suturing—  Needles — Needle-holders —  Thread — Silk — Catgut 
— Silk-worm-gnt — Horse-hair — Metal  Wire — Application  of  the  Suture — Stitchea 
of  Coaptation,  of  Approximation,  of  Relaxation  —  Knotting — Removing  the 
Stitches—  Classification  of  Sutures — Interrupted — Continuous — Pin— Quill — Bead 
— Button — Resume. 

THE  apposition  of  the   separated  surfaces  of  a  wound  is  to  be  accom- 
plished by  Position,  Bandaging,  and  Suturing. 

POSITION. 

The  advantage  to  be  derived  from  position  becomes  apparent  when 
attention  is  directed  to  the  effect  upon  the  spontaneous  gaping  of  the 
wound  of  varying  attitudes  of  the  wounded  part  A  wound  over  the  front 
of  the  knee  gapes  widely  when  the  knee  is  bent,  though  it  may  show  but 
slight  tendency  to  open  when  the  knee  is  extended.  The  edges  of  a  trans- 
verse wound  upon  the  anterior  surface  of  the  neck  fall  together  when  the 
head  is  inclined  forward,  while  a  similar  wound  on  the  back  of  the  neck  is 
made  to  gape  by  the  same  movement  Wounds  dividing  muscles  trans- 
versely gape  most  widely  when  positions  are  assumed  in  which  such  mus- 
cles are  put  upon  the  stretch.  The  general  rule,  therefore,  which  is  to  be 
observed  as  to  the  position  of  a  wounded  part,  in  attempting  to  secure 
and  maintain  apposition  of  the  wound- surf  aces,  is  that  the  part  should  be 
placed  in  that  position  in  which  the  greatest  relaxation  of  the  parts  can  be 
secured.  In  this  position  they  should  be  fixed  and  held  until  firm  union 
has  been  accomplished. 


MEANS    OF    APPROXIMATION. 


161 


BANDAGING. 

Bandages  to  approximate  separated  parts  may  be  either  roller  band- 
ages encircling  the  entire  member,  or  bandages  dressed  with  adhesive 
material  —  adhesive   plaster — short   strips   of   which,    passing   across   the 
wound  and  adhering  to  the  skin  on  either  side, 
suffice  to  keep  the  parts  apposed. 

A  simple  roller-bandage  may  be  all  that  is 
required  to  perfectly  approximate  longitudinal 
wounds,  and  wounds  in  which  there  is  little  ten- 
dency to  gape,  or  in  which  that  tendency  has 
been  overcome  by  attention  to  position.  By  the 
use  of  the  double-headed  roller,  as  in  Fig.  48, 
or  the  invaginated  bandage,  as  in  Fig.  49,  the 
tissues  may  be  made  to  slide  toward  each  other 
from  either  side,  and  perfect  apposition  be  se- 
cured in  many  cases.  In  all  deep  wounds  the 
assistance  of  a  bandage  and  of  compresses  is 
indispensable  in.  maintaining  apposition  of  the  deeper  parts  of  the 
wound.  The  compresses  should  be  placed  on  either  side  of  the  wound, 
and  upon  it,  in  such  position  that  the  encircling  bandage  shall  through  it 
produce  especial  pressure  of  the  deeper  surfaces  of  the  wound  against 
each  other.  In  the  case  of  certain  wounds,  as  of  the  face,  neck,  and 
trunk,  in  which  the  use  of  a  roller  bandage  is  impracticable,  relaxation 


FIG.  48.— Double-headed  Roller. 


FIG.  49. — The  Invaginated  Bandage. 


and  compression  of  the  wounded  parts,  so  as  to  insure  their  continued  ap- 
position, is  best  accomplished  by  carrying  broad  strips  of  adhesive  plaster 

across  the  wound,  so  as  to  grasp  the  tissues  for  some  distance  on  either 
11 


162  THE    TREATMENT    OF    WOUNDS. 

side  after  these  have  been  crowded  up  toward  the  wound  by  the  hands  of 
an  assistant,  so  as  to  take  off  all  tension  in  the  wound  itself.  Underneath 
these  strips  and  upon  the  wound  compresses  may  be  placed,  of  sufficient 
bulk  to  insure  continued  pressure  of  the  wound-surfaces  against  each 
other.  When  a  bandage  is  applied  at  any  part  of  a  limb  so  as  to  encircle 
it,  its  application  must  be  preceded  by  careful  bandaging  of  the  distal  por- 
tion of  the  limb,  from  the  fingers  or  toes  to  the  seat  of  injury,  to  prevent 
strangulation. 

Hollers. — The  material  out  of  which  the  bandages  shall  be  made  should 
be  soft,  strong,  and  somewhat  elastic,  so  as  to  adapt  itself  snugly  to  the 
parts  to  which  it  is  applied.  Cotton  cloth — muslin  sheeting — that  has 
been  repeatedly  washed  and  freed  from  the  stiffness  of  the  new  material, 
is  usually  available,  and  answers  well  the  purposes  of  a  bandage.  Material 
that  has  been  worn  until  it  is  tender  should  be  rejected.  The  loosely 
woven  cheese-cloth,  or  gauze,  when  attainable,  is  to  be  preferred,  in  most 
cases,  to  ordinary  muslin.  It  is  lighter,  cooler,  more  elastic,  and  permits 
the  passage  of  discharges  more  freely  through  it.  Cloth  of  any  kind 
should  always  be  torn  in  the  direction  of  its  length  in  making  it  into 
bandage  strips. 

Compresses. — Purified  cotton-wool  is  the  best  material  for  use  as  com- 
presses. It  is  unirritating,  light,  elastic,  and  absorbent.  Folds  of  gauze, 
masses  of  charpie,  of  oakum,  or  other  similar  substances  may  be  likewise 
used  with  advantage. 

Adhesive  Plaster. — The  ordinary  adhesive  plaster  consists  of  muslin 
which  has  been  smeared  with  a  mixture  of  litharge,  olive  oil,  resin,  and 
soap.  This  mixture,  while  fluid  by  heat,  is  spread  over  the  surface  of  the 
muslin,  and  upon  cooling  forms  a  thin  coating,  that  becomes  soft  and 
adhesive  when  again  exposed  to  heat.  When  it  is  to  be  applied,  strips 
of  suitable  size  and  length  are  cut  from  the  muslin  roll  thus  prepared, 
observing  the  precaution  to  cut  the  strips  lengthwise  of  the  cloth,  not 
transversely,  lest  they  should  stretch  unduly  after  having  been  applied. 
The  most  convenient  method  of  heating  these  strips  for  application  is  by 
pressing  their  unspread  surface  against  a  vessel,  as  a  tin  cup,  a  bottle,  a 
tea-kettle,  or  the  like,  containing  boiling  water ;  they  may  also  be  heated, 
but  less  conveniently,  by  exposing  them  to  an  open  fire,  holding  them  over 
the  chimney  of  a  lighted  lamp,  before  a  gas-light,  etc.  A  form  of  adhesive 
plaster  which  does  not  require  to  be  heated  before  it  is  applied,  was  intro- 
duced to  notice  in  1877,  by  Dr.  Henry  A.  Martin,  of  Boston,  Masa,  which 


ADHESIVE    BANDAGES.  163 

has  received  much  favor,  and,  tinder  the  name  of  "  Eubber  Plaster,"  has 
been  since  imitated  by  many  makers.  The  adhesive  coating  of  this  plaster 
is  composed  of  Para  rubber,  Burgundy  pitch,  and  balsam  of  Tolu.  It  is 
flexible,  water-proof,  comparatively  unirritating,  and  does  not  deteriorate 
with  keeping,  and  it  is  to  be  applied  at  once  without  any  preparation. 

Ichthyocolla  and  skin  plasters,  and  collodion  may  serve  as  substitutes 
for  the  ordinary  adhesive  plaster  in  the  approximation  of  small  and  super- 
ficial wounds. 

Ichthyocolla  Plaster  is  made  by  applying  to  silk  a  solution  of  isinglass  in 
alcohol  When  it  is  to  be  applied,  it  has  simply  to  be  moistened  by  pass- 
ing a  damp  sponge  over  its  glazed  surface.  Its  adhesive  properties  are 
weak,  and  it  cannot  be  used  where  there  is  moisture,  so  that  its  use  is  re- 
stricted rather  to  the  amateur  dressings  of  the  laity,  to  whom  its  greater 
elegance  of  appearance  and  the  ease  of  its  application  commend  it.  What 
is  called  court  plaster  is  a  variety  of  isinglass  plaster. 

Gold-beater's  Skin. — A  delicate  membranous  film,  made  from  the  intes- 
tine of  the  sheep  or  the  peritoneum  of  the  bullock,  when  applied  to  a 
moistened  surface  adheres  with  sufficient  firmness  to  withstand  considera- 
ble traction.  It  is  applicable  particularly  to  slight  wounds  of  the  eyelids, 
or  as  a  protective  layer  over  an  excoriated  surface. 

Collodion. — A  solution  of  freshly  prepared  gun-cotton  in  ether,  assisted 
by  a  little  alcohol,  when  applied  to  a  dry  surface,  by  the  rapid  evaporation 
of  the  ether,  leaves  a  transparent  film  that  adheres  strongly  and  contracts 
considerably.  It  may  thus  be  used  for  fastening  strips  of  silk  or  muslin  to 
the  edges  of  a  wound,  in  place  of  other  adhesive  material,  or  may  be  ap- 
plied directly  over  the  wound  as  the  only  dressing,  or  as  supplementary  to 
other  agents  in  sealing  up  the  wound.  It  is  most  useful  as  a  final  applica- 
tion to  wounds  that  have  healed,  upon  the  withdrawal  of  other  dressings, 
applied  over  the  cicatrix  which  it  protects,  giving  it  a  needed  support  in 
resisting  the  inevitable  tendency  to  reopening  of  the  wound,  which  may  be 
more  than  the  fresh  and  tender  new  uniting  material  can  withstand. 

The  Application  of  the  adhesive  Bandage. — The  skin  to  which  a  strip  of 
adhesive  plaster  is  to  be  applied  should  be  shaven,  well  washed  with  soap 
and  water,  and  carefully  dried,  to  present  a  surface  to  which  the  plaster 
can  adhere,  and  to  save  the  patient  from  the  pain  that  would  be  caused  by 
their  removal  if  the  hair  was  adherent  to  the  plaster.  One  end  of  the  strip 
is  then  to  be  pressed  upon  the  skin  upon  one  side  of  the  wound,  and  while 
the  edges  of  the  wound  are  held  together  by  the  surgeon,  the  strip  is  car- 


164  THE    TREATMENT    OF    WOUNDS. 

ried  across  and  fastened  upon  the  other  side.  Care  is  to  be  exercised  that 
inversion  of  the  edges  of  the  wound  be  not  occasioned,  and  equal  care  that 
sufficiently  firm  approximation  is  secured  to  prevent  their  after  separation. 
The  first  strip  should  be  placed  across  the  middle  of  the  wound,  and  an 
interval  of  from  one-quarter  to  one-half  an  inch  left  between  each  succeed- 
ing one,  to  admit  of  the  escape  in  the  intervals  of  wound  secretions.  As 
soon  as  strips  thus  applied  lose  their  hold,  become  sources  of  irritation  or 
obstruct  drainage,  they  should  be  removed.  But  unless  some  such  indica- 
tion exists  meddling  with  them  is  objectionable,  as  it  tends  to  do  injury  to 
the  healing  of  the  wound.  The  cleansing  of  the  wound  is  to  be  limited 
to  gently  wiping  from  the  surface  of  the  wound  and  of  the  dressings  what- 
ever secretions  may  have  gathered  there.  When  the  removal  of  the 
plasters  is  necessary,  gentleness  of  manipulation  must  be  observed  ;  the 
two  ends  of  each  strip  should  be  lifted  first,  and  the  central  part  last  de- 
tached from  the  line  of  the  wound  itself,  lest  by  dragging  the  strips  from 
one  side  to  the  other  the  wound  be  reopened. 

Objections  to  adhesive  Bandages. — The  use  of  adhesive  bandages  for  the 
purpose  of  producing  direct  apposition  of  wound-surfaces  is  objectionable 
from  its  interference  with  wound  cleanliness.  The  muslin  strips  may 
themselves  be  carriers  of  infection,  unless  they  are  disinfected  with  equal 
care  with  everything  else  that  is  allowed  to  come  in  contact  with  the 
wound.  They  may  favor  infection  again  by  sealing  up  that  portion  of 
skin  upon  which  they  are  laid  from  the  action  of  the  antiseptic  dressings 
that  may  be  applied  over  them,  and  thus  fostering  the  creation  underneath 
them  of  foci  of  sepsis  from  the  development  of  organisms  hidden  in  the 
depressions  and  follicles  of  the  skin  that  will  have  escaped  the  primary  dis- 
infection of  the  part,  however  thoroughly  done.  Still  farther,  extending  as 
they  must  some  distance  in  every  direction  from  the  wound,  as  soon  as 
they  become  wetted  with  the  wound-discharges,  they  become  favorable 
media  for  the  propagation  from  the  periphery  of  the  dressings  inward  to 
the  wound  of  micro-organisms  from  without.  In  addition  to  these  objec- 
tions, which  are  of  vital  importance  in  efforts  at  preserving  asepticity  in! 
wounds,  they  are  also  chargeable  with  being  unreliable  in  the  support  they 
may  give  from  their  tendency  to  become  loosened,  with  initating  in 
many  cases  the  skin  to  which  they  are  applied,  and,  finally,  with  covering 
up  the  wound  from  the  inspection  of  the  surgeon.  For  these  reasons,  the 
use  of  adhesive  bandages  as  direct  applications  to  wound  flaps  to  secure 
their  apposition,  should  be  abandoned  in  the  great  majority  of  cases.  For 


SUTURING.  165 

purposes  of  supplementary  support,  for  use  outside  of  the  dressings  ap- 
plied immediately  to  the  wound,  to  prevent  tension,  to  produce  compres- 
sion, and  to  insure  fixation  of  the  dressings,  they  are  invaluable. 


SUTURING. 

The  suture  is  the  most  certain,  exact,  and  important  of  all  methods  of 
obtaining  apposition  of  divided  surfaces.  Position  and  the  various  methods 
of  bandaging  are  chiefly  to  be  employed  as  supplementary  to  the  suture. 

The  application  of  the  suture  is  simply  the  use  by  the  surgeon  of  the 
tailor's  art  to  sew  together  the  separated  tissues,  and  by  a  thread  to  retain 
them  in  apposition  until  their  permanent  union  by  a  bond  of  newly-formed 
living  tissue  can  be  effected. 

Sutures  may  be  applied  superficially  and  close  to  the  wound-margins, 
simply  for  the  purpose  of  keeping  the  cutaneous  edges  of  the  wound  in 
apposition,  such  stitches  being  technically  called  "  stitches  of  coaptation  ; '' 
or  more  deeply  and  at  a  greater  distance  from  the  wound-margins  to  ap- 
proximate and  maintain  in  apposition  the  deeper  surfaces,  "  stitches  of 
approximation  ; "  or  at  a  greater  distance  yet  from  the  wound,  for  the 
purpose  of  relaxing  the  adjacent  tissues  so  that  the  wound-surfaces  may  be 
brought  together,  and  tension  upon  the  stitches  applied  to  keep  them  in 
apposition  may  be  prevented,  these  latter  constitute  "  stitches  of  relaxation." 

For  the  practise  of  the  suture  there  are  required  needles,  thread,  and 
in  some  cases  needle  forceps  for  the  more  convenient  insertion  of  the 
needles  in  the  tissues.  The  peculiarities  of  the  tissues  to  be  sewed  makes 
certain  qualities  important  to  be  possessed  by  each  of  these  agents ;  these, 
therefore,  require  consideration  here. 

NEEDLES. — The  density  and  elasticity  of  the  tissues  to  be  penetrated  by 
the  surgical  needle  makes  it  necessary  that  it  should  differ  from  the  ordi- 
nary sewing  needle  by  having  its  point  flattened,  and  the  edges  imme- 
diately following  the  point  sharp,  giving  the  forepart  of  the  needle  the 
shape  of  a  lance  (Fig.  50,  A).  The  point  should  be  fine,  and  the  cutting 
edges  should  extend  but  a  short  distance  back  from  the  point,  and  should 
exceed  in  its  transverse  diameter  that  of  the  shank  or  thread  extremity  of 
the  needle.  The  eye  should  be  as  large  as  possible,  to  avoid  delays  in 
threading,  and  its  edges  should  be  well  rounded,  so  as  not  to  cut  the 
thread.  Their  thickness  and  length  vary  greatly,  according  to  the  size  of 
the  thread  to  be  used  and  the  thickness  of  the  tissues  to  be  penetrated. 


166 


THE    TREATMENT    OF    WOUNDS. 


The  shape  of  the  needle  must  vary  with  the  locality  in  which  the  suture  is 
to  be  applied.  Upon  a  plain  or  convex  surface,  when  the  stitch  is  to  be 
introduced  but  superficially,  a  straight  or  but  slightly  curved  needle  (Fig. 
50,  A  and  B)  is  most  convenient ;  where  the  tissues  are  to  be  deeply  pene- 


\ 


A 


B  C 

FIG.  50.— Surgical  Needles. 


D 


trated,  or  the  wound  involves  a  concave  surface,  as  at  the  inner  canthus 
of  the  eye,  or  the  perineum,  strongly  curved  needles  (Fig.  50,  C  and  D) 
become  necessary. 

The  steel  of  which  they  are  made  should  not  be  too  hard,  lest  they 
break  easily.  The  chief  points  to  be  regarded  in  the  choice  of  needles  are 
that  they  have  good  points,  keen  sides,  and  sufficient  temper  to  prevent 
their  yielding  to  the  force  necessary  to  their  introduction. 

NEEDLE-HOLDERS. — When  a  suture  is  to  be  made  with  a  small  and  much 
curved  needle,  or  in  a  cavity,  the  needle  cannot  be  managed  by  the  fin- 
gers, but  must  be  seized  and  held  firmly  in  a  needle-holder.  Any  forceps 
with  short  stout  jaws,  and  long  handles  that  can  be  grasped  and  held 
firmly  in  the  hand,  will  answer  for  a  needle-holder.  The  forcipressure  for- 


FIG.  51. — The  Needle-holder  of  Dieffenbach. 

ceps  of  Wells  (Fig.  11)  are  a  good  model  The  catch,  by  means  of  which 
the  branches  are  fastened  when  they  are  closed,  adds  greatly  to  their  con- 
venience in  use. 

Fig.  51  represents  the  needle-holder  of  Dieffenbach.     Fig.  52  that  o 
Sands. 


NEEDLE-HOLDERS. 


167 


Of  the  many  models  which  have  been  constructed,  the  writer  prefers 
that  known  as  the  "Russian  Needle-holder"  (Fig.  53),  devised  by  Dr. 
Anatol  de  Gaine,  of  St.  Petersburg.  The  firmness  with  which  it  holds  the 
needle,  the  ease  with  which  by  a  simple  mechanism  it  can  be  locked  and 


FIG.  52. — The  Needle-holder  of  Sands. 

unlocked,  and  the  shape  of  its  Handles,  whereby  both  delicacy  and  power 
of  manipulation  is  secured,  constitute  its  merits. 

The  inner  surface  of  the  jaws  should  be  cut  into  stellate  grooves,  or 
should  be  lined  by  pewter,  into  which  the  needle  when  grasped  may 
sink  and  be  held  securely.  Many  varieties  of  needle-holders  have  been 
devised  to  facilitate  the  introduction  of  sutures  in  deep  cavities  and  special 
localities.  The  requirements  for  a  needle-holder  are  that  it  shall  immov- 
ably grasp  the  needle,  that  it  shall  be  of  a  shape  to  be  itself  securely 
grasped  by  the  hand  of  the  surgeon,  and  that  its  mechanism  shall  secure 
the  rapid  picking  up  and  quick  letting  go  of  the  needle. 


FIG.  53.— The  Russian  Needle-holder. 

THE  THREAD. — The  suture  requires  that  the  thread-material  shall  be 
fine  and  smooth,  sufficiently  strong  to  stand  a  certain  amount  of  strain, 
soft  and  pliable,  so  that  it  adapts  itself  well  to  the  eye  of  the  needle,  easily 
pulled  through  the  tissues  after  the  needle,  readily  tied  into  a  knot,  and 
susceptible  of  being  removed  with  equal  readiness.  The  agents  that  are 
worthy  of  special  mention  as  being  in  most  general  use,  and  as  answering 
the  purposes  of  the  suture  most  satisfactorily,  are  threads  of  silk,  of  cat- 
gut, of  silk-worm-gut,  of  horse-hair,  and  of  metal. 

Silk. — As  fine  a  thread  should  be  chosen  as  will  bear  the  strain  of  the 
suture,  for  the  observations  of  Simon  '  and  Billroth 2  have  shown  that  the 

1  Experimente  fiber  verschiedene  subxtanzen  zur  Wundnaht.     Rostock,  1863. 
'•'  Surgical  Pathology.     Hackley.     New  York,  1871. 


108  THE    TREATMENT    OF    WOUNDS. 

finer  the  thread  the  less  irritation  its  pressure  in  the  tissues  would  occa- 
sion, so  that  very  fine  ones  might  cause  no  irritation  whatever,  but  become 
healed  in  like  metal  ones.  The  finest  size  of  what  is  called,  in  the  instru- 
ment shops,  braided  ligature  silk — size  No.  1 — though  it  is  as  fine  as  a 
hair,  is  very  strong — strong  enough  to  bear  any  tension  that  ought  to  be 
put  on  a  suture,  and  does  not  kink  or  curl.  Silk  should  be  made  aseptic 
before  using  by  immersing  it  in  a  solution  of  carbolic  acid  or  of  corrosive 
sublimate,  as  described  on  page  112. 

Catgut. — Properly  prepared  and  seasoned  catgut  answers  every  pur- 
pose of  a  suture  material.  Only  that  which  has  been  prepared  after  the 
methods  described  for  catgut  ligatures,  page  110,  should  be  used  for  sut- 
ures. In  general,  after  a  few  days  the  absorption  of  the  loop  embedded 
in  the  tissues  sets  free  the  knot,  which  is  then  washed  away  or  picked 
off  without  other  manipulation  for  its  removal.  The  gut  seasoned  with 
chromic  acid — chromic  gut — resists  the  solvent  action  of  the  tissues  for 
from  ten  to  twenty  days.  Being  unirritating,  it  may  be  left  undisturbed 
as  long  as  the  wound-cicatrix  may  need  support.  The  catgut,  however,  is 
not  quite  so  manageable  as  the  aseptic  silk ;  it  is  a  little  more  troublesome 
to  tie  the  knots  securely  ;  it  is  more  difficult  to  secure  with  it  an  exact  and 
fine  coaptation  of  the  edges  of  the  wound ;  the  material  is  more  expensive 
and  the  preparation  is  more  troublesome  ;  the  spontaneous  melting  away 
of  the  loop  in  the  tissues  may  take  place  prematurely  ;  for  these  reasons  it 
has  not  supplanted  the  silk  thread  for  general  use. 

Silk-worm-guL—  This  is  made  from  the  organ  of  the  silk- worm  which 
furnishes  the  material  out  of  which  the  cocoon  is  woven.  The  threads 
obtained  are  polished,  transparent,  and  very  smooth,  and  are  especially 
distinguished  by  their  great  strength  in  comparison  with  their  thickness ; 
they  are  stronger  than  metal  threads,  and  will  remain  unchanged  in  the 
tissues  for  a  month.  They  produce  no  irritation,  but  they  have  the  dis- 
advantage of  being  somewhat  stiff,  so  that  some  difficulty  attends  tying 
them  in  a  sufficiently  strong  knot.  To  render  them  more  pliable  they 
should  be  soaked  some  time  in  water  (carbolized  or  sublimated)  before 
being  used.  Sutures  of  this  material  are  most  in  favor  among  those  sur- 
geons who  use  catgut  but  little.  They  have  been  especially  praised  for 
cases  of  ruptured  perineum  and  vaginal  fistula,  and  fissured  palate.  The 
improvements  made  in  silk  by  rendering  it  aseptic,  and  in  catgut  by 
chromicizing  it,  have  lessened  the  frequency  with  which  the  silk-worm-gut 
is  likely  to  be  resorted  to. 


SUTURE    MATERIALS.  160 

Horse-hair. — The  pliancy,  delicacy,  smoothness,  and  non-irritating 
qualities  of  horse-hair  make  it  a  desirable  substance  for  sutures,  and  it 
deserves  more  attention  than  it  has  usually  received.  It  is  strong  enough 
to  keep  the  lips  of  an  ordinary  wound  in  apposition  ;  a  double  strand  may 
be  used  if  necessary.  It  remains  unchanged  indefinitely  in  the  tissues, 
and  may  be  permitted  to  remain  as  long  as  the  support  of  a  suture  is  re- 
quired. It  can  be  applied  with  the  usual  surgical  needle,  but  needs  more 
care  in  making  a  satisfactory  knot  than  does  silk.  If.  there  is  any  tension 
upon  it,  the  first  knot  needs  to  be  held  by  a  forceps  to  prevent  slipping 
while  the  second  is  being  tied.  It  is  easily  removed  by  snipping  with  a 
pair  of  scissors,  and  withdrawal  by  an  ordinary  pair  of  forceps,  with  abso- 
lutely no  discomfort  to  the  patient,  being  in  this  respect  in  marked  con- 
trast with  metallic  sutures.  Hairs  from  the  horse's  tail,  selected  for  their 
size  and  strength,  are  to  be  preferred.  They  should  be  prepared  for  use 
by  washing  in  an  alkaline  solution,  and  should  be  immersed  in  an  anti- 
septic solution  before  being  introduced.  Its  abundance  and  the  readiness 
with  which  it  can  be  obtained,  costing  nothing  but  the  slight  trouble  of 
cleansing  it,  together  with  the  advantages  possessed  by  it,  as  enumerated, 
as  a  suture,  would  make  the  use  of  horse-hair  general  for  all  ordinary 
wounds,  were  it  not  that  the  silk  thread  is  more  convenient  to  tie  and  to 
carry  by  reason  of  its  greater  pliability.  In  default,  however,  of  proper 
silk,  it  is  a  most  valuable  substitute. 

Metal. — Fine  metallic  wires,  of  lead,  of  copper  covered  with  gutta- 
percha,  of  iron,  or  of  silver,  and  even  of  other  metals,  may  be  used  for  the 
purposes  of  a  suture  ;  by  their  smoothness,  pliability,  and  freedom  from 
irritating  properties,  they  combine  in  an  eminent  degree  the  qualifications 
demanded  for  such  use.  They  may  be  introduced  with  an  ordinary  sur- 
gical needle  like  thread,  although  a  needle  whose  head,  from  the  eye  to 
the  extremity,  is  grooved  for  the  reception  of  the  wire,  facilitates  their 
introduction ;  they  are  easily  fastened  by  twisting  the  ends  together. 
They  are  particularly  of  value  for  wounds  in  which  great  accuracy  of  co- 
aptation  is  desired,  on  account  of  the  facility  with  which  they  can  be 
readjusted  by  simply  untwisting  the  ends,  and  with  which,  also,  the  ten- 
sion they  shall  exert  may  be  regulated  by  the  degree  to  which  the  twisting 
is  carried.  They  also  tend  to  support  and  immobilize  the  tissues  through 
which  they  pass,  and  contribute  in  this  way  in  no  mean  degree  to  pro- 
moting early  union.  The  ease  with  which  they  are  fastened  adapts  them 
especially  for  use  in  deep  cavities.  There  is  no  necessity  for  their  early 


170  THE    TREATMENT    OF    WOUNDS. 

removal,  and  they  may  be  left  undisturbed  till  the  parts  are  firmly  united. 
Silver  wire  is  the  kind  of  metal  thread  most  frequently  employed.  "Wire 
made  of  it  as  fine  as  a  hair  possesses  sufficient  strength,  and  is  very  light, 
soft,  and  pliable.  The  first  use  of  it  for  sutures  was  made  by  J.  Marion 
Sims,1  in  the  treatment  of  vesico-vaginal  fistulse,  in  1849,  and  his  enthusi- 
astic advocacy  of  its  merits  in  succeeding  publications  attracted  general 
attention  to  its  use  in  general  surgery.  In  his  "  Anniversary  Discourse 
before  the  New  York  Academy  of  Medicine,"  in  1857,  he  declares  it  to  be 
his  "  honest  and  heartfelt  conviction,  that  the  use  of  silver  as  a  suture  is 
the  great  surgical  achievement  of  the  nineteenth  century ! "  The  experi- 
ments of  Simon,  already  alluded  to,  however,  demonstrated  that  there 
was  no  difference  in  the  amount  of  irritation  produced  in  the  tracks  of  a 
very  fine  well-twisted  silk  thread  and  a  fine  metal  thread  during  the  first 
eight  days  of  their  residence  in  the  tissues.  Since  both  the  introduction 
and  the  removal  of  the  wire  demands  more  care  than  silk  on  account  of 
its  inferior  softness  and  pliability,  they  are  not  so  well  adapted  as  the  fine 
silk  to  unite  wounds  the  edges  of  which  are  thin.  Even  in  uniting  the 
edges  of  the  wound  produced  in  the  operation  for  the  relief  of  vesico- 
vaginal  fistula,  in  which  Sims  first  used  silver  wire  with  so  much  advantage, 
surgeons  of  the  present  day  obtain  equally  good  results  with  silk  and  cat- 
gut. Silk  has  still  maintained  its  place,  therefore,  as  the  agent  most  gen- 
erally employed  ;  but  for  deep  sutures,  especially  those  which  are  applied 
for  the  purpose  of  relaxing  the  wound-borders,  and  for  suturing  bones, 
and  whenever  strong  tension  is  to  be  borne  by  the  suture,  and  when  the 

suture  must  remain  in  situ  for  a  long  time,  an  unqualified  preference  must 

t 
be  given  to  the  silver  wire. 

APPLICATION  OF  THE  SUTUKE. — It  is  important  as  the  first  preliminary, 
when  a  suture  is  to  be  applied,  that  the  surgeon  shall  assure  himself  of  the 
cleanliness  of  the  suture  materials,  in  the  aseptic  sense  of  the  term  clean. 
The  needles  should  be  immersed  in  a  five  per  cent,  solution  of  carbolic  acid, 
and  whatever  form  of  thread  is  deemed  best  should  have  been  rendered 
aseptic  by  previous  preparation,  and  should  likewise  be  anew  immersed  in 
the  antiseptic  solution  at  the  time  that  it  is  to  be  used. 

Before  the  introduction  of  a  suture  the  wound-borders  should  be  care- 
fully coapted  throughout  their  whole  length,  in  order  that  they  may  come 
evenly  together — not  having  a  wrinkle  in  one  place,  and  a  projecting  end 

1  The  Treatment  of  Vesico-vaginal  Fistula.  American  Journal  of  the  Medical  Sci- 
ences, January,  1852. 


APPLICATION    OF    THE    SUTURE.  171 

in  another.  To  secure  this  the  proper  points  for  entrance  and  exit  of  the 
needle  through  the  skin  should  be  noted,  and  when  the  wound  is  a  long- 
one,  it  will  be  best  to  introduce  the  first  stitch  in  the  centre.  If  the  new 
stitches  on  either  side  are  likewise  placed  half-way  between  the  first  one 
and  the  angles  of  the  wound,  the  long  wound  is  thereby  changed  into 
four  small  ones,  the  perfect  adjustment  of  whose  edges  is  much  facili- 
tated. 

If  several  sutures  are  to  be  applied,  it  is  better  to  have  the  necessary 
number  of  needles  already  threaded  and  conveniently  placed  within  reach. 
Not  only  is  the  delay  neces- 
sary to  newly  thread  a  needle 
in  the  course  of  the  operation 
inconvenient,  but  it  is  more 
likely   to   be    attended   with 
some  infraction  of  the  laws  of 
cleanliness. 

The  needle  should  be 
seized  by  the  right  hand  so 
that  the  middle  finger-  shall 
be  on  the  one  side  and  the 

FIG.  54.— The  Seizure  of  the  Keedle  (Fischer). 

thumb  on  the  other,  and  the 

index  finger  by  the  side  of  the  middle  finger  where  the  needle  is  curved, 
with  both  ends  of  the  thread  hanging  thrown  over  the  backs  of  the  fingers. 
(See  Fig.  54.)  The  border  of  the  wound  should  then  be  steadied  by  seizing 
it  with  a  forceps  or  tenaculum,  while  the  needle  is  made  to  transfix  the  tis- 
sues. When  the  wound,  flap  is  sufficiently  extensive  and  free,  it  may  be 
fixed  by  grasping  it  with  the  thumb  and  finger  of  the  left  hand.  Upon  a 
convex  surface,  or  even  a  flat  surface,  when  the  stitch  is  to  be  very  super- 
ficial, it  is  possible  to  depress  the  eye  end  of  the  needle,  and  to  elevate  the 
wound-borders  sufficiently  to  enable  the  transfixion  to  be  made  with  a 
straight  needle,  but  on  a  concave  portion  of  the  surface  of  the  body,  as  be- 
tween the  nose  and  cheek,  the  palm  of  the  hand,  perineum,  etc.,  a  curved 
needle  is  required.  Since  also  a  curved  needle  is  equally  of  use  on  any 
surface,  it  is  the  instrument  ordinarily  and  generally  used  for  any  suture. 
The  needle  should  pass  through  the  tissues  in  a  line  about  equal  to  its 
own  curvature  ;  when  but  a  small  amount  of  tissue  is  to  be  included  in 
the  suture,  the  needle  entering  and  escaping  near  the  line  of  intended 
union,  a  short  and  strongly  curved  needle  is  needed ;  if  the  suture  is  to  be 


172 


THE    TREATMENT    OF    WOUNDS. 


introduced  at  a  greater  distance  from  the  wound-edge,  a  longer  and  less 
strongly  curved  needle  is  required. 

The  distance  from  the  edge  at  which  the  needle  shall  be  introduced, 
and  the  depth  to  which  it  shall  be  carried  will  depend  upon  the  particular 
function  the  suture  is  intended  to  discharge.  For  a  stitch  of  coapta- 
tion,  the  needle  will  be  introduced  from  two  to  three-sixteenths  of  an  inch 
from  the  edge,  and  will  be  thrust  through  the  skin  into  the  subcutaneous 
connective  tissue  only.  Stitches  of  approximation  will  be  introduced  at  a 
greater  distance,  and  will  pass  more  deeply  among  the  tissues.  The  two 
may  be  used  alternately.  Fig.  55  illustrates  the  arrangement  and  rela- 


FIG.  55. — Stitches  of  Coaptation  and  Approx- 
imation Introduced  {Fischer). 


FIG.  56. — The  Interrupted  Suture.     The 
Knotting  of  the  Suture  (Fischer). 


tions  of  these  two  kinds  of  stitches.  When  deep  sutures  are  inserted  a 
tendency  to  incurvation  of  the  wound-edges  is  produced,  to  overcome 
which  requires  care  to  alternately  elevate  either  edge  with  a  tenaculum  or 
forceps  as  the  suture  is  tied. 

When  the  point  of  the  needle  has  emerged  from  the  opposite  flap  of 
the  wound,  it  is  to  be  seized  with  the  fingers,  or  forceps,  and  drawn 
through,  carrying  a  sufficient  length  of  thread  after  it  to  admit  of  being 
conveniently  tied  into  a  knot  The  ends  are  then  brought  together  so  as 
to  bring  the  wound-surfaces  into  apposition  and  tied  into  a  secure  knot. 
The  various  steps  of  this  knotting  of  the  suture  are  depicted  in  Fig.  56. 
The  suture  must  not  be  drawn  so  tightly  as  to  strangulate  the  tissues  em- 
braced in  its  loop.  A  suture  drawn  too  tightly  will  speedily  provoke  in- 


APPLICATION    OF   THE    SUTURE.  173 

flammation  and  suppuration.  Nor  must  the  suture  be  subjected  to  much 
elastic  tension  of  the  tissues,  otherwise  the  tissues  will  cut  themselves 
upon  the  unyielding  thread  until  the  suture  becomes  loose.  When  the 
tissues  are  lax  the  ordinary  reef-knot,  Fig.  57,  should  be  made  as  the 
most  secure  form  of  a  knot. 

If  there  exists  much  tendency  to  gaping  in  forming  the  first  knot,  the 
thread  may  be  passed  twice  through  the  same  noose,  Fig.  58,  so  that  the 
adhesion  of  the  threads  is  increased  sufficiently  to  resist  the  tendency  to 
retraction  of  the  edges  until  the  second  simple  knot  can  be  tied.  This  is 
what  is  termed  the  "surgical  knot."  If  the  two  lips  can  be  held  in  appo- 
sition by  an  assistant  while  the  knot  is  tied,  the  surgical  knot  will  be 
superfluoua 


Fta.  57. — Reef-knot.  FIG.  58. — Surgical  Knot. 

The  knot  must  not  be  tied  so  as  to  come  in  the  wound-line,  but  must 
be  tied  on  one  side  so  as  to  press  upon  the  sound  integument,  for  when 
the  knots  are  permitted  to  press  directly  upon  the  line  of  the  wound  they 
are  liable  to  produce  irritation. 

The  distance  between  the  points  of  suture  must  vary  according  to  cir- 
cumstances, depending  upon  the  tendency  to  gape  of  the  tissues,  and  the 
importance  for  securing  union  by  first  intention  of  the  most  accurate  appo- 
sition possible.  In  no  case  should  there  be  allowed  any  gaping  in  the 
intervals  between  the  stitches.  The  intervals  may  vary  from  one-eighth  to 
one-half  or  three-quarters  of  an  inch.  No  fixed  rule  can  be  laid  down, 
either,  as  to  the  succession  in  which  the  stitches  shall  be  applied,  beyond  the 
general  principle  that  the  stitches  of  relaxation  are  to  be  first  applied,  then 
the  stitches  of  approximation,  and  finally  the  stitches  of  coaptation.  It  is 
easily  apparent  when  the  wound-edges  are  brought  together  at  what  point 
the  first  stitch  should  be  placed.  In  angular  wounds  the  point  of  the  angle 
should  first  be  secured,  and  subsequently  the  stitches  should  be  placed 
elsewhere,  so  that  the  borders  throughout  shall  come  smoothly  together. 


174  THE    TREATMENT    OF    WOUNDS. 

The  stitches  may  be  removed,  as  a  rule,  in  about  three  days  ;  but  unless 
their  longer  residence  in  the  tissues  is  attended  with  evident  disadvantage, 
as  shown  by  a  tendency  to  produce  irritation  and  ulceration,  it  is  better  to 
leave  them  undisturbed  for  forty-eight  hours  longer.  When  there  has 
been  much  tension  necessary  to  bring  the  edges  of  the  wound  together, 
too  early  removal  of  the  stitches  is  especially  to  be  avoided.  A  week  or 
ten  days  is  time  enough.  By  the  use  of  aseptic  sutures  the  necessity  for 
speedy  removal  of  the  thread  is  overcome,  and  the  needs  of  the  new  unit 
ing  tissue  for  support  can  be  more  exclusively  considered. 

To  remove  the  stitches,  the  knot  should  be  seized  with  a  dressing  for- 
ceps, elevated  slightly  from  the  integument,  so  that  the  point  of  a  scissors 
can  be  insinuated  beneath  it  to  cut  the  thread  beyond  it  The  thread  is 
then  drawn  carefully  out,  while  the  tissues  are  steadied  by  the  scissors 
pressing  upon  them,  and  traction  is  made  upon  the  thread  in  a  direction 
toward  the  line  of  cicatrix  lest  the  wound  be  torn  open  anew  by  the  pro- 
ceeding. The  stitches  first  to  be  removed  should  be  those  of  the  least 
importance.  In  general,  they  will  be  removed  in  the  reverse  order  of  that 
with  which  they  were  introduced.  After  their  removal,  the  parts  should 
be  supported  for  a  time  by  strips  of  adhesive  plaster,  when  the  wound  is 
in  a  locality  where  they  can  be  applied,  and  the  line  of  the  cicatrix  and 
the  immediately  adjacent  skin  should  be  covered  with  a  layer  of  collodion. 

CLASSIFICATION  OF  SUTURES. — According  to  the  different  methods  used 
for  the  successive  application  of  the  stitches,  or  the  different  devices  used 
for  exerting  pressure  upon  the  tissues,  sutures  are  divided  into  interrupted, 
continuous,  pin,  quill,  bead,  and  button  sutures. 

INTERRUPTED  SUTURE. — The  interrupted  suture  is  formed  of  a  series  of 
separate  stitches  (Fig.  56).  It  is  more  generally  used  than  any  other  form 
of  suture ;  indeed,  the  pin,  quill,  button,  and  bead  sutures  are  but  forms 
of  this  suture.  Stitches  of  relaxation  and  of  approximation,  in  all  cases, 
require  to  be  of  this  form.  It  is  the  typical  suture,  and  all  that  has  pre- 
ceded with  reference  to  the  technique  of  the  suture  is  particularly  appli- 
cable to  the  interrupted  suture. 

CONTINUOUS  SUTURE. — This  suture,  on  account  of  its  similarity  to  that 
used  by  the  glover,  is  frequently  spoken  of  as  the  "  glover's  suture."  The 
stitches  of  which  it  is  composed  are  not  separate,  but  are  made  with  the 
same  needle  and  thread,  in  continuous  succession,  by  passing  the  needle 
diagonally  from  one  side  of  the  wound  to  the  other  over  the  surface,  and 
through  the  tissues,  until  the  whole  extent  of  the  wound  has  been  tra- 


THE    CONTINUOUS    SUTURE.  175 

versed  (Fig.  59).  Though  this  form  of  suture  is  especially  adapted  for 
sutures  of  coaptation,  it  had  until  recently  been  almost  entirely  discarded, 
except  in  the  sewing  up  of  wounds  of  the  intestines.  In  nearly  all  cases, 
however,  it  is  superior  to  the  interrupted  suture  for  coaptation  purposes 
by  reason  of  its  greater  simplicity,  the  greater  rapidity  with  which  the 
necessary  coaptation  can  be  secured,  the  more  even  and  accurate  appo- 
sition of  the  edges  which  it  accomplishes,  and  the  increased  support  to 
the  whole  line  of  the  union  that  it  gives.  The  resulting  cicatrix  will  be 
more  finely  linear  than  can  be  obtained  in  any  other  way.  In  applying 
the  continuous  suture,  a  comparatively  short,  fine,  aseptic  silk  or  catgut 
thread  should  be  used,  which,  with  a  straight  or  curved  needle,  accord- 
ing as  the  peculiarities  of  the  locality  may  require,  is  introduced  at  one 


Fia.  59. — The  Continuous  Suture. 


angle  of  the  wound,  where  it  is  tied  as  for  the  interrupted  suture,  Tind 
thence  is  carried  with  oblique  stitches  along  the  coapted  wound-mar- 
gins to  the  other  end  of  the  line  of  separation.  Here  the  thread  is  fas- 
tened by  leaving  the  superficial  loop  connecting  the  last  two  stitches  so 
loose  that  by  cutting  it  a  free  end  is  left  which  is  tied  to  one  end  of  the 
last  stitch  after  this  has  been  tied  as  an  ordinary  interrupted  suture.  For 
its  removal,  each  superficial  loop  should  be  cut  with  the  point  of  a  scis- 
sors, converting  it  into  as  many  points  of  interrupted  suture,  each  one  of 
which  should  then  be  carefully  withdrawn  as  before  described. 

PIN  SUTURE. — This  form  of  suture,  Fig.  60,  known  also  as  the  twisted, 
and  hare-lip  suture,  consists  in  transfixing  the  apposed  margins  of  a  wound 
with  metallic  pins,  and  then,  while  the  wound  surfaces  are  kept  approxi- 
mated by  pressure  from  the  finger's  of  an  assistant,  the  two  projecting  ends 
of  the  pin  are  encircled  with  a  thread,  which  is  then  earned  several  times 
around  the  pin,  over  the  line  of  the  wound  elliptically,  and  in  the  shape  of 
the  figure  8,  and  lastly  is  secured  by  a  knot. 

As  a  pin  to  be  used  for  the  purposes  of  this  suture,  the  ordinary  glass- 


176 


THE   TREATMENT    OF    WOUNDS. 


headed  ladies'  toilet  pin,  Fig.  61,  is  not  surpassed  by  any  other  device.  It 
is  very  sharp-pointed,  and  readily  penetrates  the  tissues  ;  it  is  unirritating  ; 
it  is  quickly  procurable,  and  is  cheap.  The  German  insect-pin,  Fig.  60, 
which  is  made  of  brass  with  a  ball  head,  and  a  flattened,  lance-shaped 
point,  likewise  makes  an  excellent  agent.  Transfixion  is  effected  in  the 
same  manner  as  in  the  common  interrupted  suture,  the  thumb  and  finger 
being  generally  quite  sufficient  for  the  purpose.  The  pins  should  be 
thrust  as  deeply  into  the  tissues  as  is  compatible  with  bringing  them  out 
again  at  a  corresponding  point  upon  the  surface  of  the  opposite  flap.  All 
the  pins  that  are  to  be  inserted  should  be  put  in  place  before  the  thread  is 


PIG.  CO.— The  Pin  Suture. 


Fio.  61.— Pin  for  Twisted  Suture, 


applied,  otherwise  the  insertion  of  the  second  pin  will  pull  unduly  upon 
the  first  suture.  The  distance  from  the  wound  edges  of  the  points  of  en- 
trance and  exit  of  the  pins  will  be  from  one  quarter  to  half  an  inch.  The 
distance  between  the  phis  will  depend  upon  the  degree  to  which  the  wound 
borders  tend  to  gape,  and  the  amount  of  motion  to  which  it  will  be  ex- 
posed. Each  pin  should  be  separately  wound  about  with  the  thread, 
which  should  then  be  cut  and  tied.  In  place  of  thread,  narrow  rings  of 
rubber  may  be  used  to  slip  over  the  ends  of  the  pins,  and  to  compress  the 
wound-borders.  The  points  of  the  pins  should  then  be  cut  off  with  a  pair 
of  pliers  to  prevent  their  sticking  into  the  skin.  If  there  is  a  tendency 
evident  for  the  ends  of  the  pins  to  press  unduly  into  the  skin,  this  may  be 
protected  by  a  strip  of  adhesive  plaster  inserted  beneath  the  extremities 


THE    PIN    SUTURE.  17  f 

of  the  pins.  The  practice  of  taking  a  much  longer  thread  and  carrying  it 
from  one  pin  to  another,  making  a  cross  likewise  over  the  wound  between 
the  pins  with  the  thread,  as  it  passes  from  pin  to  pin,  has  the  advantage  of 
aiding  their  coaptation  by  the  gentle  pressure  which  it  makes  upon  them, 
but  this  can  be  better  accomplished  by  superficial  sutures  placed  between 
the  pins,  as  in  Fig.  60,  which  may  remain  to  support  the  tissues  still  longer 
after  the  pins  have  been  withdrawn.  The  earlier  removal  of  the  pins  with- 
out disadvantage  is  thus  made  possible  ;  this  should  be  done  in  from  two 
to  three  days,  even  earlier  if  the  pins  show  a  tendency  to  cut  their  way 
out.  When  they  are  to  be  removed  the  wound  edges  should  be  gently 
pressed  together  by  the  left  thumb  and  forefinger,  applied  upon  the  ends 
of  the  twisted  loops,  the  head  of  the  pin  should  be  grasped  by  an  ordinary 
dressing-forceps,  by  gentle  rotation  their  adhesion  in  the  line  of  their  pen- 
etration loosened,  and  then  withdrawn.  The  thread  loops,  which  ai-e  glued 
to  the  skin  by  dried  blood,  may  be  left  in  place  for  a  day  or  two  longer, 
as  a  bond  of  union,  until  they  become  spontaneously  detached.  All  the 
pins  may  be  removed  at  the  same  time,  or  at  different  times.  In  the  latter 
case,  those  will  first  be  removed  that  are  least  useful. 

The  pin  suture  is  .especially  applicable  in  cases  where  there  has  been 
considerable  loss  of  integument,  and  where  considerable  strain  upon  the 
tissues  is  necessary  to  bring  them  together.  When  the  parts  are  very 
movable,  as  in  the  lips  and  cheeks,  arid  also  when  the  wound  involves  skin 
that  is  so  thin  and  lax  that  the  wound  edges  manifest  a  strong  tendency  to 
roll  in.  A  much  more  frequent  use  of  the  pin  suture  might  be  made  with 
advantage  than  is  now  usual.  Though  primarily  it  is  important  as  a  means 
of  approximation  when  the  divided  surfaces  are  first  brought  into  apposi- 
tion, its  secondary  effect,  to  keep  immovable  and  to  support  the  united 
wound  is  no  less  important,  and  may  make  its  use  desirable  when  the  first 
indication  does  not  call  for  it.  The  results,  in  general,  of  attempts  to  ob- 
tain union  by  first  intention  in  wounds  of  any  extent  will  be  much  more 
uniformly  successful  by  the  use  of  the  pin  suture,  as  a  matter  of  routine 
practice,  than  by  relying  simply  on  the  ordinary  suture  and  bandaging. 

THE  QUILL  SUTURE. — This  suture  consists  in  the  application,  on  either 
side  of  the  wound,  at  a  little  distance  from  its  edges,  and  parallel  with 
them,  of  little  rods  of  some  smooth  and  unirritating  substance,  as  a  quill, 
bougie,  whalebone,  or  soft  wood,  around  which  threads  passed  deeply 
across  the  wound  were  looped,  so  that  when  they  were  drawn  upon  and 

tied,  the  pressure  of  the  rods  would  bring  and  hold  together  the  deep 
12 


THE   TREATMENT    OF    WOUNDS. 


parts  of  the  wound,  and  would  relax  the  superficial  parts,  which  were  also 
secured  by  superficial  stitches  of  the  interrupted  or  continuous  suture. 
The  arrangement  is  shown  in  Fig.  62  and  Fig.  63. 

In  making  this  suture,  several  needles  should  be  threaded  by  passing 
both  ends  of  the  thread  through  the  eye  of  the  needle,  so  as  to  form  a 
loop  on  the  middle  of  the  thread.  The  double  thread  is  then  to  be  passed, 
as  deeply  as  may  be  necessary,  through  the  wound-borders  as  for  an  ordi- 
nary interrupted  suture.  A  sufficient  number  of  threads  having  been 
introduced,  instead  of  crossing  them  and  tying,  a  rod  is  slipped  through 
the  loops  on  the  one  side  of  the  wound,  which  are  then  tightened  from  the 
other  side  by  drawing  on  the  free  ends.  A  similar  rod  is  then  placed  be- 
tween the  free  ends  of  the  threads,  and  upon  this  they  are  firmly  tied, 


FIG.  62. — Quill  Suture.    In  course  of  application. 


FIG.  63.— Quill  Suture.     Appli- 
cation completed. 


beginning  with  the  central  threads,  which  are  drawn  down  upon  the  rod 
until  by  its  pressure'  the  wound  surfaces  are  brought  into  close  apposition. 
A  secure  knot  is  then  tied,  and  the  application  of  the  apparatus  is  com- 
plete. This  form  of  suture  was  used  by  the  older  surgeons  for  closing 
deep  muscular  wounds,  as  those  of  the  thigh  and  abdomen  ;  and  by  later 
surgeons  more  particularly  for  the  repair  of  lacerations  of  the  perineum. 
It  is  efficient  both  as  a  suture  of  approximation  and  relaxation,  but  for 
these  purposes  has  been  mostly  superseded  by  the  bead  and  the  button 
suture  in  some  form.  In  wounds  in  situations  where  the  additional  sup- 
port of  compresses  and  bandages  are  impracticable,  it  will,  howrever,  always 
remain  as  a  device  of  great  value  for  securing  primary  accurate  deep  appo- 
sition and  consecutive  immobilization  and  support  during  the  healing  of 
the  wound.  For  its  removal,  after  three  to  five  days,  the  loops  are  cut 
with  scissors  on  the  one  side,  and  the  threads  drawn  out  on  the  other. 


THE   BEAD    SUTURE. 


179 


THE  BEAD  SUTURE. — This  is  an  interrupted  suture  in  which  two  sutures 
are  joined  in  one  so  that  a  bead  at  either  lateral  extremity  of  the  suture 
has  a  wire  or  tliread  passing  through  the  centre  of  the  bead.  The  twist 
of  the  two  ends  of  the  wire  enables  the  operator  to  tighten  or  loosen  the 
tension  after  the  suture  line  is  closed.  This  is  a  very  desirable  quality  of 
a  stitch  in  a  situation  like  that  of  the  interior  of  the  mouth,  the  stitch 
having  no  covering,  and  the  suture  line  having  no  possible  support  except 
that  of  the  stitches  themselves.  This  suture  is  equally  applicable  to 
wounds  in  the  vagina,  where  any  sup- 
port to  the  stitches  is  impracticable.  It 
is  thus  described  by  Dr.  David  Prince, 
of  Jacksonville,  HL' 

The  accompanying  cut  (Fig.  64)  rep- 
.+  resents  the  suture  in  three  stages:  (1) 
The  completed  suture,  the  beads  lying 
upon  the  natural  surface  of  the  skin  or 
mucous  membrane.  The  tightening  or 
loosening  of  the  twist  of  the  ends  of  the 
wire  increases  or  diminishes  the  tension. 
The  dotted  line  indicates  the  course  of 
the  wires  or  threads  through  the  tissues. 
At  the  bottom  of  the  figure  is  seen  (2) 
the  same  stitch  incomplete.  The  open 
condition  of  the  wound  shows  the  wire 
passing  through  the  cut  surfaces.  The 
suture  can  be  so  introduced  into  mem- 
branous, or  in  thin  walled  parts,  that  the  wire  will  lie  upon  the  surface 
opposite  to  that  upon  which  the  beads  rest,  if  it  is  preferred.  The  position 
of  the  forceps,  by  which  the  ends  of  the  wire  are  twisted,  is  seen  in  the 
cut  (3).  The  double-beaded  suture,  in  which  (in  the  cut)  the  beads  ai*e 
seen  to  he  in  a  slit  made  parallel  to  the  suture  line,  in  order  to  enable  the 
opposite  surfaces  to  come  into  contact  with  each  other.  The  beads  sink 
into  these  incisions,  and,  as  the  wires  pass  through  the  tissues  between  the 
surfaces  of  a  thin  wall,  there  is  no  folding  of  the  parts  to  prevent  the  cut 
surfaces  of  the  suture  line  from  being  held  in  close  and  accurate  contact. 

The  object  in  using  two  beads  on  a  side  is  to  increase  the  work  done 


FIG.  M.— The  Bead  Suture. 


'  The  Bead  Suture.     Annals  of  Anatomy  and  Surgery,  March,  1883.  p.  142. 


180  THE    TREATMENT    OF    WOUNDS. 

by  two  wires,  or  a  single  wire  bent  upon  itself,  and  to  increase  the  scope 
of  applied  pressure.  In  place  of  two  spherical  beads,  a  single  elliptical 
one  may  be  employed.  The  polished  glass  bead  is  friendly  to  the  sur- 
faces, and,  on  account  of  its  smoothness,  it  is  superior  to  a  sphere  of  lead. 
No  attention  is  required  to  adjvist  spherical  beads,  and,  as  they  He  loosely 
upon  the  silver  wire,  they  are  ready  when  the  wire  is  cut,  at  the  final  re- 
moval of  the  stitches,  to  slip  off  without  difficulty.  The  manner  of  intro- 
duction is  very  simple  and  easy.  A  pilot  thread  is  first  carried  through  in 
the  situation  in  which  the  wire  is  to  be  subsequently  introduced.  A  simi- 
lar pilot  thread  is  then  carried  tlirough  on  the  opposite  side.  Each  pilot 
thread  is  double,  and  the  loop  ends  are  so  related  to  each  other  that  one 
thread  may  be  included  in  the  loop  of  the  other,  by  which  it  is  drawn 
through.  A  silver  wire  is  then  drawn  in  by  the  remaining  thread.  A 
bead  (or  two  as  the  case  may  be)  is  slipped  tipou  the  wire,  after  which  it 
is  hooked  upon  the  loop  of  the  next  thread  and  drawn  in.  The  two  ends 
of  the  silver  wire  are  then  on  the  same  side.  A  bead  (or  two  as  the  case 
may  be)  is  then  slipped  on  to  one  end  of  the  wire,  after  which  the  applica- 
tion of  the  forceps  is  made  preparatory  to  the  final  twist.  In  the  removal 
of  the  suture,  the  wire  may  be  cut  at  either  end  and  on  either  side  of  the 
bead.  The  bead  straightens  the  wire  in  slipping  off,  so  that  traction  upon 
the  other  bead  pulls  the  wire  out,  appearing  then  in  the  shape  of  a  staple. 

There  are  many  situations  in  which  the  employment  of  the  beaded 
suture  will  be  found  convenient  and  efficient.  The  principle  of  this  stitch 
is  not  new,  only  the  form  and  material  of  it.  When  this  stitch  is  em- 
ployed upon  the  soft  palate  it  answers  the  purpose  of  a  suture  and  a  splint 
at  the  same  time,  and  holds  in  continuous  apposition  parts  that  are  in  mo- 
tion with  every  act  of  swallowing  and  speaking.  The  same  advantage 
exists  in  operations  for  the  closure  of  rents  in  the  vagina,  where  move- 
ments occur  in  connection  with  the  evacuation  of  the  rectum  and  of  the 
bladder. 

THE  BUTTON  SUTURE. — For  the  purpose  of  securing  relaxation  of  the 
more  distant  tissues,  so  that  the  wound  surfaces  may  be  approximated  and 
coapted,  the  most  efficient  device  is  some  form  of  metal  plate,  or  button, 
placed  on  either  side  of  the  wound  at  appropriate  distances,  and  joined 
by  silver  wire  which  is  passed  deeply  through  the  tissues  from  plate  to 
plate  across  and  at  the  bottom  of  the  wound.  Traction  upon  the  wires, 
suffices  to  draw  together  the  tissues  pressed  upon  by  the  plates  and  to 
relax  the  intervening  tissues.  Whenever  a  considerable  gap  exists,  such 


THE    BUTTON    SUTURE. 


181 


sutures  are  of  great  value  in  facilitating  healing,  and  should  generally  be 
employed.  Various  forms  of  plates  have  been  used.  None  are  more  sim- 
ple and  efficient  than  the  form  devised  by  Mr.  Lister,  Fig.  65,  which  con- 


FIG.  65. — Lead  Button  for  Stitch  of  Relaxation  (Cheyne). 

sists  of  a  flat  plate  of  lead,  about  one-twentieth  of  au  inch  in  thickness, 
cut  of  an  oval  form,  with  lateral  wings,  which  are  turned  up,  and  afford 
projecting  edges  about  which  the  end  of  the  wire  is  wound  in  a  figure  of 
8  form,  while  the  wire  for  the  suture  passes  out  through  a  hole  that  has 
been  perforated  through  the  centre  of  the  plate.  Fig.  66,  from  MacCor- 
mac's  "Antiseptic  Surgery,"  illustrates  the  method  of  the  application  of  this 


FIG.  6<i. — The  Button  Suture  Applied  (JfacCormac). 


lead  plate  or  button.  On  the  one  side  the  wire  is  seen  to  be  secured  by 
winding  it  about  the  projecting  wings  as  described  ;  on  the  other  it  is 
secured  by  a  split  shot  which  has  been  clamped  upon  it.  Another  simple 


182 


THE    TREATMENT    OF    WOUNDS. 


and  ingenious  method,  suggested  by  Thiersch,  of  Leipsic,  is  also  figured  by 
MacCormac,  from  which  the  accompanying  cut  (Fig.  67)  and  description, 
are  borrowed. 

Outside  a  leaden  plate  is  placed  a  small  perforated  glass  bead,  which 


>r 

FIG.  67. — The  Bead  Suture  of  Thiersch. 

distributes  the  pressure,  and  outside  the  bead  the  wire  is  wound,  till  a 
sufficient  degree  of  tension  is  secured.  If  the  wire  becomes  loose,  one  or 
further  turns  will  sufficiently  tighten  it,  or  the  suture  can  be  relaxed,  if  it 
be  thought  desirable.  With  a  piece  of  sheet  lead,  a  few  beads,  a  box  of 
matches,  and  some  silver  wire,  anyone  may  get  ready  such  sutures  with 


PlQ.  68. — Arrangement  of  Stitches  of  Relaxation,  of  Approximation,  and  of  Coaptation  to  Close  Wound 
after  Removal  of  Mamma  and  Axillary  Glands  (Chcyne). 

very  little  trouble.  The  arrangement  and  function  of  the  button  stitches  of 
relaxation  is  well  shown  in  the  accompanying  illustration  from  Cheyne's 
"Antiseptic  Surgery."  (Fig.  68.) 


PKINCIPLES    OF    WOUND-APPOSITION.  183 

In  conclusion,  it  will  be  well  to  repeat  that  while  in  different  wounds 
different  conditions  calling  for  differing  devices  for  obtaining  apposition  of 
the  divided  surfaces  may  be  found,  the  great  principles  will  always  be  the 
same,  and  must  each  be  regarded,  if  the  best  result  possible  is  to  be  ob- 
tained. These  principles  are  embodied  in  the  three  words,  relaxation,  ap- 
proximation, and  coaptation.  When  these  have  been  secured,  the  next  duty 
of  the  surgeon  in  the  treatment  of  a  wound  is  to  protect  the  injured  parts 
from  disturbance  of  every  kind  till  repair  is  complete. 


CHAPTER  X. 

PROTECTION    AGAINST     DISTURBANCES     OF    HEALING— ANTISEP- 
TIC  DRESSINGS. 

Cotton  Wool—  Berated  —  Salicylated — Carbolated  —  Sublimated — lodof ormized  —  Bis- 
muth—  Gauze — Carbolated — lodof  orrnized  —Naphthalinated — Lint—  Tow — Oakum 
— Naphthalinated  Oakum — Jute —  Turf-Mould —  CJutrcoal — Aluminated  Charcoal — 
Sand — Sublimated  Sand — Coal  Ashes — Sawdust — Wood-  Wool — The  Protective — 
The  External  Impermeable  Envelope — Bandages — The  Method  of  Lister — The  lodo- 
form  Dressing  of  BiUroth — EsmarcJi's  Turf-Mould  Dressing. 

Ix  the  further  history  of  a  wound,  it  will  be  necessary  that  protective 
dressings  be  applied,  by  which  it  shall  be  kept  from  septic  infection,  from 
direct  mechanical  violence,  and  from  motion,  and  by  which  also  the  com- 
pression and  warmth  needed  to  promote  nutrition  shall  be  maintained, 
until  healing  is  complete. 

Septic  infection  is  to  be  guarded  against  by  covering  the  part  with  soft 
and  absorbent  materials  that  will  receive  and  keep  aseptic  the  discharges 
that  drain  away  from  it,  and  that  will  purify  from  septic  particles  the  air 
that  passes  through  them  to  the  wound.  For  this  purpose  many  sub- 
stances may  be  found  useful  Among  those  more  commonly  employed  are 
cotton-wool  and  loosely  woven  cotton  cloth,  gauze  and  lint,  tow,  jute,  turf- 
mould,  charcoal,  sand,  and  sawdust.  To  the  natural  absorbent  properties 
of  these  materials  it  is  necessary  only  to  add  the  presence  throughout 
their  substance  of  a  sufficient  amount  of  some  antiseptic  material  to  de- 
stroy or  to  render  inert  any  septic  germs  that  may  be  brought  in  contact 
with  it  Materials  thus  prepared  constitute  antiseptic  dressings,  the  prepa- 
ration of  the  more  important  of  which  will  next  demand  attention. 

ANTISEPTIC   DRESSINGS. 

Cotton  Wool — Ordinary  cotton  wool  should  first  be  purified  and  ren- 
dered hygroscopic  by  washing  it  in  an  alkaline  solution  and  drying.  It  is 
thus  prepared  on  a  large  scale  by  different  manufacturers  in  this  country 


ANTISEPTIC    COTTON    WOOL.  185 

and  sold  as  "  absorbent  cotton."  Its  preparation  for  a  wound  dressing  is 
completed  by  charging  it  with  boracic  acid,  salicylic  acid,  carbolic  acid, 
iodoform,  corrosive  sublimate,  or  other  antiseptic. 

Borated  Cotton. — Hot  water  dissolves  fifteen  per  cent,  of  its  weight  of 
boracic  acid,  but  on  cooling  precipitates  ah1  but  four  per  cent.  If  the  cot- 
ton be  treated  with  an  equal  weight  of  a  saturated  hot  solution  of  boracic 
acid  and  then  dried,  it  will  remain  permanently  charged  with  fifteen  per 
cent,  of  the  antiseptic  substance,  which  is  a  desirable  strength  to  have  to 
insure  its  antiseptic  properties.  Borated  cotton  thus  prepared  has  the 
acid  intimately  incorporated  into  the  substance  of  its  fibres  and  is  free 
from  loose  particles  of  the  crystals  lying  among  its  meshes. 

Salicylated  Cotton. — This  is  usually  made  of  tAvo  strengths,  4  per  cent 
and  10  per  cent.  Salicylic  acid  requires  300  paiis  of  cold  water  for  its 
solution  ;  boiling  water  dissolves  it  in  the  proportion  of  1  to  25,  but  much 
of  a  given  quantity  of  the  acid  is  volatilized  by  the  heat  of  such  a  solution, 
making  its  permanent  strength  unreliable. 

Alcohol  takes  it  up  in  large  quantity,  and  a  dilute  spirit  makes  the  best 
menstruum  with  which  to  charge  a  dressing.  As  the  fine  crystals  depos- 
ited in  the  interstices  of  the  wool  are  liable  to  shake  out,  a  small  propor- 
tion of  glycerine  should  also  be  added.  The  following  formula  will  insure 
the  preparation  of  the  10  per  cent  strength  : 

Glycerine 2  parts  by  weight. 

Water 100      " 

Alcohol 20      " 

Salicylic  acid 2 

Cotton  wool 20      " 

The  solution  of  the  acid  having  been  made  in  the  menstruum,  with  the 
aid  of  very  gentle  heat,  the  mixture  should  be  placed  in  a  flat  vessel,  in 
which  the  wool  should  be  laid  in  layers,  each  being  thoroughly  saturated 
before  the  next  is  superimposed.  When  the  whole  mass  has  thus  soaked 
for  about  ten  minutes,  it  is  turned  upside  down,  the  layers  taken  off  in  the 
order  that  they  were  put  on,  and  laid  aside  to  dry,  flat,  and  in  a  warm 
room.  The  antiseptic  properties  of  the  wool  may  be  still  farther  increased 
by  dipping  a  thin  layer  of  it  in  a  ten  per  cent,  solution  of  the  acid  in  gly- 
cerine, applying  this  first  to  the  wound,  and  over  this  a  thick  layer  of  the 
dry  salicylated  wool  sufficient  ii  extend  widely  beyond  011  ah1  sides. 


186  THE    TREATMENT    OF    WOUNDS. 

Garbolated  Cotton. — Cheyne  mentions  a  carbolized  wool  prepared  by 
soaking  pure  cotton  wool  in  a  one  per  cent,  solution  of  carbolic  acid  in 
ether,  the  cotton  to  be  then  dried  and  used  immediately.  Its  use  is  re- 
stricted on  account  of  the  volatility  of  the  agent,  and  on  account  of  the 
superiority  of  the  gauze  preparation  of  the  same  agent. 

Sublimated  Cotton. — Corrosive  sublimate  may  be  diffused  through  cot- 
ton by  saturating  it  in  an  alcoholic  solution  of  not  more  than  one-half  of 
one  per  cent,  strength.  A  stronger  solution  should  not  be  used  lest  irri- 
tation of  the  skin  be  produced,  resulting  in  eczema  and  bullse.  The  fol- 
lowing formula  is  recommended  by  Kummell : 

Alcohol 449  parts. 

Glycerine 50  parts. 

Corrosive  sublimate 1  part. 

Saturate  the  cotton,  and,  having  passed  it  through  a  clothes-wringer, 
expose  it  to  dry. 

lodoformized  Cotton  may  be  prepared  by  soaking  the  wool  in  an  ethe- 
real solution  of  iodoform,  as  follows  : 

lodoform 50  parts. 

Ether 250     « 

Alcohol 750     " 

and  permitting  the  fluid  to  evaporate,  or,  extemporaneously,  by  rubbing 
the  powder  into  the  cotton,  and  shaking  out  the  surplus. 

Naphthalinated  Cotton  may  be  obtained  by  making  a  saturated  solution 
of  naphthalin  in  benzine,  and  steeping  the  wool  in  it  for  a  short  time. 
By  exposing  it  in  thin  layers  for  a  short  time,  the  benzine  evaporates  per- 
fectly, and  leaves  the  wool  charged  with  the  antiseptic. 

Bismuth  Cotton. — The  subnitrate  of  bismuth  should  be  finely  pow- 
dered, and  then  gradually  and  very  intimately  triturated  with  water,  in 
proportions  to  make  a  ten  per  cent,  emulsion,  in  which  the  cotton  may  be 
dipped,  as  needed,  and  used  at  once  after  expressing  the  fluid. 

Cotton  wool  may  be  sufficiently  charged  with  any  of  the  antiseptic 
powders  for  many  purposes  by  simply  nibbing  into  the  meshes  of  the 
wool,  at  the  time  it  is  to  be  used,  the  dry  fine  powder. 

GAUZE. — Loosely  woven  cotton  cloth  is  more  largely  used  as  an  absorb- 
ent dressing  for  wounds  than  any  other  material,  and  is  technically  known 


CAKBOLATED    GAUZE.  187 

as  "  gauze."  It  is  the  foundation  of  the  great  mass  of  the  antiseptic  dress- 
ing introduced  by  Mr.  Lister,  who  first  mentioned  it  in  the  British  Medical 
Journal  for  January,  1871.  The  cloth  should  first  be  prepared  by  boiling 
it  in  a  weak  solution  of  carbonate  of  soda  and  chloride  of  lime,  to  thor- 
oughly cleanse  and  disinfect  it.  This  may  be  done  in  an  ordinary  wash- 
boiler.  The  cloth  is  then  dried,  when  it  will  be  found  to  have  become 
much  more  absorbent  than  before.  Thus  prepared,  it  may  be  impreg- 
nated with  various  antiseptics,  and  kept  for  use. 

Carbolated  Gauze. — G-auze  impregnated  with  carbolic  acid  is  the  mate- 
rial generally  employed  by  Mr.  Lister  as  a  dressing  to  guard  against  the 
entrance  of  causes  of  fermentation  into  a  wound  after  an  operation,  and  is 
to  be  provided  whenever  the  so-called  Lister  dressing  is  to  be  applied. 
Carbolated  gauze  cannot  be  kept  for  any  length  of  time  without  deteriora- 
tion, by  reason  of  the  evaporation  of  the  cai-bolic  acid.  It  cannot  be  kept 
in  permanent  store.  Hence  only  that  which  has  recently  been  prepared 
should  be  used.  While  for  general  use  by  the  surgeon  in  private  practice 
who  desires  to  have  by  him  a  preparation  of  gauze  that  may  be  drawn 
upon  for  occasional  dressings  from  time  to  time,  some  other  and  more 
stable  antiseptic  is  required.  A  great  many  different  ways  of  preparing 
gauze  have  been  published,  but,  on  the  authority  of  Mr.  Cheyne,1  Mr. 
Lister's  colleague  and  assistant,  none  are  so  good  as  the  following,  which 
can  be  used  in  any  hospital,  and  which  was  recently  employed  during 
the  Russo-Tui'kish  War  for  making  fresh  gauze  in  camps.  The  materials 
to  be  used  are  : 

Crystallized  carbolic  acid 1  part. 

Common  resin 4  parts. 

Paraffin -4  parts. 

These  materials  are  to  be  mixed  together  and  added  to  an  equal  weight  of 
the  cleansed  gauze.  The  technique  of  the  charging  process  is  as  follows  : 

The  paraffin  and  resin  are  first  melted  together  in  a  water-bath,  after 
which  the  acid  is  added,  and  blended  by  stilling.  The  object  now  is  to 
diffuse  this  melted  mixture  equally  through  the  cotton-cloth,  and  for  this 
purpose  two  things  are  requisite,  viz.,  that  the  cotton  be  at  a  higher  tem- 
perature than  the  melting-point  of  the  mixture,  and  that  it  be  subjected  to 
moderate  pressure  after  receiving  it.  The  cloth,  a  yard  wide,  is  cut  into 

1  Antiseptic  Surgery,  p.  63. 


188  THE   TREATMENT    OF   WOUNDS. 

six  yard  lengths,  and  these  having  been  folded  so  as  to  be  half  a  yard 
square,  are  placed  in  a  dry  hot  chamber,  formed  of  two  tin  boxes  placed 
one  within  the  other,  with  an  interval  to  receive  water,  which  is  kept  boil- 
ing by  fire  or  gas  beneath,  the  upper  edges  of  the  boxes,  being  connected 
and  provided  with  an  exit-pipe  for  the  steam.  There  is  also  a  glass  pipe 
arranged  as  a  gauge  of  the  amount  of  the  water,  and  the  chamber  has  a 
properly-fitting  lid.  The  bottom  of  the  chamber  is  strengthened  with  an 
iron  plate,  to  enable  it  to  bear  the  weight  used  for  compressing  the  gauze 
when  charged.  There  is  a  piece  of  wood  about  two  inches  thick,  nearly 
fitting  the  chamber,  covered  with  sheet  lead,  so  as  to  make  it  about  as 
heavy  as  a  man  can  lift  by  means  of  two  handles  in  the  upper  surface. 
The  weight  is  heated  along  with  the  cotton,  and  is  put  first  into  the  cham- 
ber so  as  to  leave  the  cotton  loose  for  the  penetration  of  the  heat,  which 
occupies  two  or  three  hours.  The  cotton,  when  heated,  is  taken  out  of  the 
chamber  along  with  the  weight,  and  placed  in  a  wooden  box  to  protect  it 
from  the  cold.  (It  would  be  better  to  have  a  second  hot  chamber  for  this 
purpose,  since  in  cold  weather  the  cotton  is  apt  to  be  too  much  cooled,  in 
spite  of  the  protection  of  the  wooden  box.)  The  heated  gauze  is  then  at 
once  charged  with  the  melted  mixture  of  carbolic  acid,  resin,  and  paraffin, 
in  quantity  equal  to  the  weight  of  the  cotton  fabric  (or  slightly  less) ;  and 
in  order  to  diffuse  the  liquid  as  equally  as  possible,  it  is  sprinkled  over  the 
gauze  by  means  of  a  syringe  with  a  number  of  minute  perforations  in  its 
extremity,  the  body  of  the  syringe  and  the  piston-rod  having  each  a 
wooden  handle  to  protect  the  hands  of  the  workman  from  the  heat  The 
syringe  is  constructed  to  hold  half  the  quantity  of  the  mixture  required 
for  charging  one  piece  of  cloth.  One  folded  piece  being  placed  at  the 
bottom  of  the  hot  chamber,  its  upper  half  is  raised  and  turned  aside,  and 
one  syringeful  is  sprinkled  over  the  lower  half.  The  upper  half  is  then 
put  back  into  position  and  another  syringeful  thrown  on.  The  same 
process  is  repeated  with  all  the  other  pieces  of  gauze,  after  which  the 
weight  is  put  into  the  chamber  to  compress  the  charged  cotton,  and  the 
lid  applied.  An  hour  or  two  are  then  allowed  to  elapse,  to  permit  the 
complete  diffusion  of  the  liquid,  when  the  material  is  fit  for  use. 

In  this  gauze  the  carbolic  acid  is  the  only  active  agent ;  the  resin  is 
used  to  prevent  the  acid  from  being  washed  out  too  soon  by  the  discharge, 
while  the  paraffin  is  employed  to  lessen  the  adhesiveness  of  the  resin. 
The  gauze  ought  to  be  kept  in  a  tin  box,  closing  tightly,  to  prevent  evap- 
oration of  the  carbolic  acid. 


IODOFOKMIZED    GAUZE.  189 

An  efficient  gauze  may  be  prepared  according  to  the  formula  of  von 
Brnns,  by  taking 

Carbolic  acid 10  parts. 

Resin 40      " 

Castor  oil 8 

Alcohol 200      " 

The  resin,  powdered,  is  to  be  slowly  added,  with  constant  stirring,  to 
the  alcohol.  When  the  solution  is  complete  the  carbolic  acid  and  the  cas- 
tor oil  are  likewise  stirred  in.  In  place  of  the  castor  oil,  glycerine  or 
melted  stearine  may  be  used,  the  quantity  to  be  used  being  of  equal  weight 
with  the  acid.  The  alcohol,  also,  may  be  replaced  by  benzine,  as  a  sol- 
vent, and  the  expense  of  the  preparation  be  much  reduced.  The  gauze  is 
to  be  simply  soaked  in  this  mixture,  being  well  kneaded  to  secure  its  uni- 
form diffusion,  and  then  hung  up  to  allow  the  spirit  to  evaporate.  It  will 
be  dry  enough  to  be  ready  for  use  or  storing  in  from  five  to  ten  minutes. 
The  whole  operation  demands  neither  much  time  nor  skill,  nor  any  partic- 
ular apparatus.  Gauze  thus  prepared  contains  about  nine  per  cent,  of 
carbolic  acid. 

In  order  to  make  the  gauze  dressing  more  reliably  antiseptic,  the  layers 
of  gauze  which  go  next  the  wound  should  be  dipped  in  a  watery  solution 
of  carbolic  acid,  1  to  40,  immediately  before  being  applied. 

Carbolated  gauze  that  has  been  used  may  be  washed  and  recharged 
with  the  cai'bolic  acid  mixture.  It  may  then  be  used  again. 

lodoformized  Gauze  may  be  prepared  by  roughly  rubbing  the  crystals 
into  the  meshes  of  the  cloth.  Gauze  thus  prepared  constitutes  the 
ordinary  "  absorbent  iodoform  gauze  "  of  Billroth.  In  preparing  it  the 
loosely  crumpled  gauze  should  be  put  into  a  clean  receptacle — a  wash- 
basin rinsed  out  with  carbolic  lotion — and  plentifully  sprinkled,  by  means 
of  a  pepper-box,  with  the  iodoform  powder.  This  should  then  be  worked 
in  with  the  hands  until  the  whole  of  the  gauze  is  uniformly  yellowed  by 
the  powder.  Then  the  excess  of  the  iodoform  is  to  be  gotten  rid  of  by 
shaking,  after  which  it  is  ready  for  use.  It  should  be  kept  in  sealed  flat 
glass  jars.  The  amount  of  iodoform  retained  by  the  gauze  after  the  shak- 
ing will  be  from  ten  to  twenty  per  cent.  An  ounce  of  iodoform  will  im- 
pregnate thus  between  four  and  five  yards  of  gauze. 

This  form  of  gauze  may  be  applied  directly  to  all  wounds,  except  those 


190  THE   TREATMENT   OF    WOUNDS. 

in  the  cavity  of  the  mouth.  It  absorbs  very  readily,  does  not  endanger 
retention,  does  not  irritate  like  carbolic  gauze,  and  does  not  readily  pro- 
voke iodoform  intoxication. 

An  "  adhesive  gauze  "  may  be  prepared  by  soaking  the  gauze  in  an 
alcoholic  solution  of  resin,  to  which  glycerine  is  added,  and  dusting  the 
iodoform  upon  the  sticky  surface  left  after  it  has  been  wrung  out  and  half 
dried,  just  as  in  the  preparation  of  the  absorbent  gauze.  For  priming  the 
gauze  the  following  formula  is  used  : 

Kesin 100  parts. 

Alcohol  (95  per  cent.) 1,200      " 

Glycerine 50      " 

Nearly  four  times  as  much  iodoform  is  retained  by  this  gauze  as  by 
the  unprepared  fabric.  It  is  of  especial  value  in  dressing  wounds  in  the 
cavity  of  the  mouth,  and  for  application  as  a  compress  upon  surfaces  from 
which  parenchymatous  hemorrhage  is  taking  place. 

Naphthalinated  Gauze. — Five  yards  of  gauze  may  be  charged  with  naph- 
thalin  by  using  the  following  mixture  (Fowler)  : 

Naphthalin 1  ounce. 

Paraffin 2  ounces. 

Glycerine 2  ounces. 

Alcohol 2  ounces. 

The  paraffin  is  first  melted.  The  glycerine  and  alcohol  are  then  mixed 
together  and  added  to  the  melted  paraffin ;  lastly,  the  naphthalin  is 
stirred  into  the  mixture,  which  is  kept  heated  and  well  stirred  until  the 
latter  is  all  dissolved.  The  gauze  is  dipped  into  the  mixture  while  the 
latter  is  hot  It  is  then  passed  immediately  between  the  rollers  of  a  com- 
mon clothes-wringer  to  squeeze  out  all  the  superfluous  fluid.  After  a  few 
minutes'  exposure  to  allow  evaporation  of  the  alcohol,  it  is  ready  for  use. 
It  should  be  kept  in  closely  covered  tin  cans. 

Another  method  is  to  make  a  saturated  solution  of  naphthalin  in  ben- 
zine, in  which  the  gauze  is  soaked  for  a  few  hours  for  a  day  or  two.  The 
material  is  then  hung  up  on  a  line  to  dry  until  the  benzine  has  all  evapo- 
rated (Park). 

A  solution  majr  likewise  be  made  of  the  naphthalin  in  four  parts  ether, 


OAKUM JUTE.  191 

to  which  an  equal  quantity  of  alcohol  is  added  (Fischer),  in  which  the 
gauze  may  be  dipped. 

LINT  may  be  prepared  in  any  of  the  ways  that  have  been  described  as 
applicable  to  cotton-wooL 

Tow. — Flaxen  or  hempen  fibres  may  act  as  substitutes  for  the  cotton, 
and  may  be  treated  in  the  same  ways.  They  are  inferior  in  absorbent 
qualities,  and  are  less  soft  in  texture  than  the  cotton.  Impregnated  with 
tar  they  form  oakum  which  forms  an  excellent  wound-dressing  in  many 
conditions,  but  it  has  only  feeble  antiseptic  properties.  Oakum  may  be 
charged  with  other  antiseptics  in  addition  to  the  tar,  and  be  of  especial 
value  as  a  cheap  material  to  form  the  outer  layer  of  dressings.  Its  fibres 
are  too  harsh  to  make  it  a  desirable  substance  to  place  in  immediate  con- 
tact with  a  wound. 

An  excellent  dressing  can  be  quickly  extemporized  from,  the  prepared 
oakum,  known  as  "  marine  lint,"  and  iiaphthalin,  by  picking  the  former 
into  loose  masses  and  sprinkling  it  over  with  the  latter  and  then  rubbing 
the  antiseptic  well  into  the  meshes  of  the  oakum.  The  tar  in  the  oakum 
causes  the  naphthalin  to  adhere  firmly  to  its  fibres  and  in  sufficiently 
large  quantities  to  answer  all  the  purposes  of  a  rigid  antisepsis  (Fowler). 

JUTE  has  been  largely  used  as  a  wound-dressing  on  account  of  its  cheap- 
ness and  great  absorbent  power.  This  is  a  vegetable  fibre  obtained  chiefly 
from  Bengal,  and  brought  in  large  quantities  to  the  New  York  market, 
where  it  is  used  in  the  manufacture  chiefly  of  mats  and  coarse  woven  stuffs. 
It  is  one  of  the  most  cheaply  raised  and  prepared  of  all  fibres.  The  best 
qualities,  which  alone  are  suitable  for  surgical  use,  have  a  clear  white, 
yellowish  color,  with  a  fine,  silky  lustre.  The  fibres  are  soft  and  smooth 
to  the  touch,  and  are  fine,  long,  and  uniform.  They  are  composed  of  from 
thirty  to  one  hundred  fibrillse,  flattened  in  external  shape,  and  tubular  in 
the  centre,  which  well  adapts  them  for  the  absorption  and  retention  of  an 
antiseptic  medium. 

Jute  dipped  in  a  ten  per  cent,  solution  of  carbolic  acid  in  spirit  dries 
quickly  and  retains  a  large  quantity  of  carbolic  acid,  as  much  as  six  to 
eight  per  cent,  for  ten  or  twelve  days. 

Jute  may  be  impregnated  with  various  antiseptics  in  the  same  ways  as 
have  already  been  described  for  cotton-wooL  It  should  be  cleaned  before 
impregnation.  The  fluids  that  drain  out  of  it,  when  it  is  hung  up  to  dry, 
should  be  again  poured  over  it,  until  they  are  all  taken  up. 

TURF-MOULD. — The  dust  or  mould  obtained  from  carbonized  turf — peat 


192  THE   TREATMENT    OF    WOUNDS. 

— has  been  used  as  a  wound-dressing  with  great  advantage  by  Esmarch 
and  Neuber,1  of  Kiel  The  advantages  claimed  for  it  are  these  : 

1.  A  given  quantity  of  the  mould  takes  up  more  fluid  than  jute,  gauze, 
or  cotton  wool.  If  it  be  lightly  moistened,  its  absorbent  power  is  still  in- 
creased ;  wounds  remain  perfectly  dry  under  it.  2.  It  possesses  a  great 
power  of  absorbing  products  of  decomposition  of  organic  substances,  and 
hence  prevents  the  same  from  occurring,  and  acts  even  in  the  unprepared 
form.  3.  The  moistened  mould  is  a  very  soft  but  still  elastic  substance,  so 
that  it  is  easily  placed  in  the  required  position  in  the  bags  before  applying 
them  to  the  inequalities  of  the  body.  4.  It  is  the  cheapest  of  known  anti- 
septic dressings,  one  pennyworth  sufficing  for  a  dressing,  and  will  be  more 
so  when  it  is  found  that  the  preparation  with  some  antiseptic  can  be  left 
out.  5.  It  makes  a  very  suitable  pad  for  all  purposes  when  enclosed  in 
gauze. 

To  increase  its  antiseptic  pi'operties,  the  mould  may  be  impregnated 
with  carbolic  acid,  chloride  of  zinc,  or  iodoform. 

CHARCOAL. — Powdered  charcoal,  by  its  quality  of  absorption  and  nitra- 
tion of  fluids,  is  well  fitted  for  a  wound-dressing.  It  is  possessed  of  anti- 
septic properties  in  its  natural  state,  and  is  one  of  the  oldest  disinfectants 

used  in  medicine. 

• 

Aluminated  CJiarcoal. — Ktimmel  recommends  the  addition  of  acetate  of 
alumina  to  charcoal  to  increase  its  antiseptic  properties.  It  is  to  be  pre- 
pared by  first  baking  the  finely  powdered  charcoal  for  several  hours  and 
then  mixing  it  with  powdered  aceto-tartrate  of  alumina  in  the  proportion  of 

Charcoal 7  parts. 

Aceto-tartrate  of  alumina 3  parts. 

If  the  mixture  contains  equal  parts  of  the  ingredients  it  produces  a 
slight,  irritation  of  the  fresh  wound-surface,  and  even  in  the  present  pro- 
portions this  irritation  sometimes  occurs.  After  a  few  days,  however,  the 
irritation  disappears,  giving  place  to  a  healthy  granulating  surface.  A 
smaller  proportion  of  the  alum  would  prevent  the  irritation  without  dimin- 
ishing the  antiseptic  properties  of  the  mixture. 

Wound  cavities,  where  primary  union  is  impossible,  may .  be  filled  in 
with  this  aluminated  charcoal  and  covered  with  a  few  layers  of  gauze  and 
any  impermeable  material.  The  first  dressing  may  often  be  allowed  to 


1  Erfahrungen  fiber  Iodoform-  und  Torfrerbdnde  in  dcr  chir.  Klinik  des  Herrn  Es- 
march.     By  Dr.  G.  Neuber,  ArcJiie  fur  Kliniaclie  Chirurgie,  1882.  Band  xxvii.,  p.  757. 


SUBLIMATED    SAND.  193 

remain  one  to  two  weeks  without  a  change.  In  small  wounds  healing 
takes  place  as  under  a  scab. 

SAND. — A  fine  quality  of  purified  sand,  common  white  quartz-sand,  has 
also  been  used  with  great  advantage  in  the  General  Hospital  of  Hamburg 
(Kiimmell)  as  a  wound-dressing.  It  is  easily  obtained,  is  cheap,  and  can 
readily  and  quickly  be  made  aseptic.  After  having  been  passed  through 
a  fine  sieve,  it  should  be  heated  several  hours  in  a  covered  pan.  Directbr 
after  cooling  it  should  be  mixed  with  an  ethereal  solution  of  corrosive  sul>- 
limate  and  be  afterward  preserved  in  glass-stoppered  bottles. 

Sublimated  Sand, — An  efficient  and  reliable  antiseptic  sand  may  be 
made  according  to  the  following  formula  : 

Corrosive  sublimate 10  parts. 

Ether 100     " 

Sand 10,000     " 

— 150  grains  of  the  sublimate  being  sufficient  to  impregnate  20  Ibs.  of 
sand.  It  may  be  used,  like  other  antiseptic  powders,  to  fill  wound  cavities, 
being  covered  with  sublimated  gauze  over  which  a  gauze  bandage  is  fast- 
ened. The  use  of  an  impermeable  outer  covering  is  objectionable,  as 
thereby  desiccation  is  prevented,  and  healing  under  a  scab  impeded.  In 
consequence  of  the  fine  grain  of  the  sand,  it  may  be  instilled  into  narrow 
fissures  and  recesses.  The  dressing  may  remain  in  place  for  weeks  till 
healing  has  taken  place,  by  simply  renewing  the  layers  of  gauze  as  they 
become  impregnated  with  the  wound-secretions.  Before  replacing  the 
layers  of  gauze,  the  wound  should  be  irrigated  with  a  solution  of  the  sub- 
limate, and  the  sand,  where  missing,  renewed.  The  sublimated  sand  pro- 
motes in  a  marked'  manner  dryness  in  a  wound.  This  it  does  by  decreas- 
ing the  amount  of  the  secretions  and  by  absorbing  whatever  moisture  may 
occur.  Frequently  it  was  found,  upon  removal  of  the  firmly  dried  crust 
of  sand,  that  the  wound  had  healed  as  under  a  scab.  Rarely  do  particles 
of  sand  remain  in  the  healed  wound.  If  they  do,  they  are  harmless.  The 
sand  may  also  be  used  as  a  dressing  for  wounds  that  have  been  sutured 
for  primary  union,  a  light  layer  of  lint  or  wool  being  first  laid  over  the  line 
of  suture. 

COAL-ASHES. — Finely  sifted  coal-ashes,  on  account  of  their  lightness,  in- 
organic nature,  and  absorbent  properties,  are  adapted  for  wound-dressings. 
Their  chemical  composition  consists  of  elements  more  or  less  antiseptic  in 
their  nature,  which  may  be  increased  by  wetting  them  with  an  antiseptic 


194  THE    TREATMENT    OF    WOUNDS. 

solution.1  Kiimmell  has  substituted  sublimated  ashes  for  sand  in  many  in- 
stances. According  to  this  surgeon,  the  best  ashes  for  the  purpose  consist 
of  the  fine  and  light  powder,  called  flying  ashes,  which  settles  in  large 
quantities  behind  the  fire-boxes  of  steam  boilers.  Cushions  filled  with 
this  latter  substance  form  admirable  means  of  compression,  being  soft  and 
pliable  and  readily  adapting  themselves  to  the  shape  of  the  parts  to  which 
they  are  applied.  Cushions  filled  with  the  prepared  ashes  for  ordinary 
purposes  of  wound-dressing  are  moistened  just  prior  to  being  used,  in 
order  to  facilitate  their  absorbent  action.  It  is  recommended  to  use  sev- 
eral small  cushions  rather  than  one  large  one  in  the  dressing. 

SAWDUST. — As  a  cheap  and  readily  obtained  absorbent  dressing,  bags  of 
sawdust,  impregnated  with  iodoform,  corrosive  sublimate  or  carbolic  acid, 
have  been  used  in  the  New  York  Hospital  and  have  answered  well* 

WOOD-WOOL. — From  Professor  Bruns,  of  Tubingen,  we  receive  a  fresh 
addition  to  our  means  for  carrying  out  the  after-treatment  of  wounds,  in 
the  form  of  a  preparation  which  he  calls  "  wood-wool,"  and  which  he  rec- 
ommends to  surgeons.3  Fine-grained  wood  in  the  form  of  splinters  and 
shavings,  such  as  are  largely  employed  in  paper  factories,  according  to 
Bruns,  is  the  kind  of  material  to  be  used  in  preparing  the  dressing  which 
is  called  wood-wooL  Pine  wood  is  preferred,  and  especially  the  pinus  picea, 
which  is  poorer  in  resin  and  of  coarser  grain  as  compared  with  the  wood 
of  other  pines  and  firs.  The  further  preparation  of  the  wood  shavings  and 
splinters  consists  in  their  reduction  to  a  state  of  finer  division  by  being 
rubbed  through  a  wire  sieve,  then  dried,  and  finally  impregnated  with 
various  antiseptic  substances.  That  considered  best  is  a  half  per  cent  of 
corrosive  sublimate  and  ten  per  cent  of  glycerine  (the  percentage  appar- 
ently referring  to  the  ratio  between  these  substances  and  the  wood-wool). 
The  advantages  of  such  a  dressing  are  believed  to  be  manifold.  Compared 
with  ashes  and  turf  it  is  absolutely  clean,  fresh,  and  of  white  color,  and  is 

1  Kiimmell  gives  the  following  as  the  average  composition  of  the  ash  of  English 

coal: 

Sulphuric  acid 8.38 

Phosphoric  acid. 1.18 

Silicic  acid 61.66 

Lime 2. 62 

Magnesia 1.62 

Oxide  of  iron  and  alumina 24.42 

*E.  F.   Weir:    Dressings  for  Wounds,  New  York   Medical  Journal,  January   6, 

1883,  p.  6.  a  Berl.  Klin.  Woch.,  1883,  No.  20. 


THE    PROTECTIVE.  195 

soft  and  pliable  like  ordinary  wool,  and  withal  of  extraordinary  cheapness. 
It  possesses,  in  virtue  of  its  contained  resin,  ethereal  oils,  certain  antisep- 
tic properties,  and  is  so  easily  adapted  to  the  wounded  parts,  and  of  such 
elasticity,  that  a  uniform  and  equable  pressure  is  easily  obtained.  Its 
principal  property,  however,  is  its  extraordinary  power  of  taking  up  fluids  ; 
in  this  it  excels  all  other  forms  of  dressings  ;  it  absorbs  twelve  times  its 
own  weight  of  fluid,  so  that  ten  grams  of  dried  "  wood-wool,"  after  com- 
plete saturation,  weigh  one  hundred  and  thirty  grams.  Simple  sawdust 
absorbs  only  three  or  four  times  and  a  half  its  weight  of  water,  ashes  only 
nine-tenths,  and  sand  only  four-tenths.  This  dressing  has  been  in  use  by 
Bruns  for  half  a  year,  and  he  has  every  reason  to  be  greatly  satisfied  there- 
with. With  the  exception  of  one  case  of  erysipelas,  no  secondary  accidental 
wound  diseases  were  met  with. 

THE  PROTECTIVE. — Whenever  the  direct  contact  with  the  wound  surfaces 
of  these  dressings  would  chemically  or  mechanically  irritate  them,  as  is 
especially  the  case  with  those  that  are  impregnated  with  carbolic  acid,  it 
is  best  to  apply,  over  the  exposed  wound  surface,  a  layer  of  some  aseptic 
neutral  and  unirritating  substance  as  a  protective,  over  and  around  which 
the  antiseptic  dressings  shall  be  placed.  Such  a  layer  will  be  of  use  also 
in  preventing  the  dressing  from  sticking  to  the  wound,  and  in  preventing 
the  formation  of  scabs,  and  the  consequent  possible  retention  of  the  dis- 
charges. The  material  so  used  is,  in  general  parlance,  distinguished  by 
the  technical  name  of  the  Protective. 

The  special  material  employed  by  Mr.  Lister,  in  connection  with  his 
carbolic  acid  dressings,  consists  of  oiled  silk  coated  with  copal  varnish. 
When  this  is  dry  a  mixture  of  one  part  of  dextrine,  two  parts  of  pow- 
dered starch,  and  sixteen  parts  of  cold  watery  solution  of  carbolic  acid 
(1  to  20),  is  brushed  over  the  surface.  The  rationale  of  this  method  of 
preparation  is  the  following  (Cheyne)  :  Oiled  silk  alone  is  better  for  the 
purpose  of  a  protective  than  gutta-percha  tissue,  because  carbolic  acid 
does  not  so  readily  pass  through  it  It  does,  however,  do  so,  and 
therefore  copal  varnish,  which  is  almost  absolutely  impermeable  to  car- 
bolic acid,  is  added.  As,  however,  the  fluid  collects  on  this  as  on  a 
duck's  back,  leaving  intervals  between  each  drop  on  which  dust  may  fall 
and  escape  the  action  of  the  acid,  the  dextrine  solution  is  added,  and  the 
result  is  that  when  moistened  the  whole  surface  of  the  protective  remains 
uniformly  wet  The  use  of  the  carbolic  acid  in  the  dextrine  solution 
is  not  to  add  any  carbolic  acid  to  the  protective,  but  because  it  is  better 


196  THE    TREATMENT    OF    WOUNDS. 

than  water  for  enabling  the  dextrine  to  adhere  to  the  varnished  oiled-silk. 
For  the  same  reason  the  powdered  starch  is  added.  The  original  carbolic 
acid  flies  off  very  quickly  from  the  protective,  leaving  a  material  containing 
no  antiseptic  in  its  substance. 

This  protective  should  always  be  dipped  in  an  antiseptic  solution  (car- 
bolic acid  1  to  40,  or  corrosive  sublimate  1  to  1,000)  before  being  applied 
to  the  wound  surface. 

Although  the  dextrine-copal-oiled  silk  of  Lister  is  a  superior  form  of 
protective  material,  it  is  not  indispensable,  and,  when  it  cannot  be  con- 
veniently obtained,  may  be  substituted  with  very  good  effects  by  ordinary- 
rubber  tissue. 

When  less  irritating  agents  than  carbolic  acid,  as  salicylic  and  boracic 
acids,  are  used  for  impregnating  the  dressings,  the  protective  is  of  less 
importance.  The  powder  dressings,  as  turf-mould,  iodoform,  naphtha- 
lin,  bismuth,  etc.,  are  best  applied  without  the  intervention  of  a  protective. 

Cheyne  calls  attention  to  the  frequent  error  of  putting  on  too  large  a 
piece  of  protective.  There  is  nothing  antiseptic  in  its  substance,  and  it 
protects  the  discharge  beneath  it  from  the  action  of  the  antiseptic  in  the 
other  dressing  materials.  Therefore  if  at  any  part  it  projects  beyond  or 
comes  close  to  the  edge  of  the  dressing,  it  allows  the  causes  of  putrefaction 
to  spread  inward  beneath  it,  and  prevents  the  antiseptic  from  acting  on 
this  putrefying  discharge.  It  is  therefore  a  very  good  rule,  he  remarks, 
having  covered  the  wound  with  sufficient  protective,  to  look  on  this  pro- 
tective as  a  wound,  and  to  be  as  careful  in  having  the  gauze  dressing  over- 
lap it  in  all  directions  as  if  it  were  itself  the  wounded  surface.  Where 
there  is  very  little  space  for  overlapping,  no  protective  ought  to  be  applied. 
It  is  better  to  have  somewhat  slower  healing  than  to  have  putrefaction 
spread  into  the  wound. 

EXTERNAL  IMPERMEABLE  ENVELOPE. — For  the  purpose  of  arresting  the 
evaporation  of  the  antiseptic  when  it  is  volatile,  and  to  prevent  the  secre- 
tion which  soaks  through  the  dressing,  if  it  should  come  directly  to  the 
external  surface,  from  being  there  exposed  to  atmospheric  influence,  and 
becoming  septic,  in  close  proximity  to  the  wound,  the  dressings  may  be 
enveloped  in  some  thin  impermeable  material  This  is  of  special  impor- 
tance in  carbolic  acid  dressings  on  account  of  the  volatility  of  the  acid  and 
the  excessive  serous  oozing  which  it  provokes.  The  material  used  by  Mr. 
Lister  is  composed  of  cotton  cloths  with  a  thin  layer  of  india-rubber  spread 
on  one  side,  called  Macintosh  cloth.  In  its  use  care  is  to  be  taken  that  the 


BANDAGES.  197 

side  on  which  the  rubber  is  spread  should  go  next  the  wound,  and  that  it 
should  be  without  a  rent,  pin-hole,  or  other  defect.  The  presence  of  a 
small  opening  more  or  less  completely  neutralizes  the  object  and  endangers 
the  failure  of  the  antisepsis.  As  less  expensive  than  the  Macintosh  cloth, 
rubber  tissue,  waxed  paper  or  paraffin  paper  are  used  as  substitutes,1  but 
they  are  less  reliably  impermeable  than  the  Macintosh.  The  same  piece 
of  Macintosh,  if  thoroughly  cleaned  and  disinfected,  may  be  used  several 
times. 

The  use  of  an  impermeable  external  envelope  is  open  to  the  very 
serious  objection  that  it  keeps  the  skin  underneath  it  moist  from  retained 
perspiration,  and  by  its  moist  warmth  promotes  the  activity  of  whatever 
sources  of  putrefaction  may  escape  the  antiseptic  cares  that  have  been 
taken.  It  tends  to  envelop  the  wound  in  putrefiable  material  so  that  the 
more  frequent  and  more  copious  application  of  antiseptics  is  required  to 
secure  continued  freedom  from  sepsis.  With  the  introduction  of  less  vola- 
tile and  less  irritating  substances  as  antiseptics  than  carbolic  acid  it  has 
been  possible  to  abandon  the  use  of  any  impermeable  covering. 

BANDAGES. — For  the  purpose  of  adjusting  and  retaining  the  dressings  in 
place,  bandages  of  various  widths  are  required.  If  the  case  requires  their 
direct  application  upon  the  deeper  parts  of  the  dressing,  they  should  be 
made  of  antiseptic  gauze.  Gauze  that  has  been  primed  with  the  resin 
mixture  (page  189)  has  the  advantage  that  each  turn  of  the  Bandage  made 
of  it  adheres  to  the  previous  one,  giving  additional  security  to  the  dress- 
ing. If  carbolic  gauze  is  used,  it  should  always  be  dipped  in  carbolic 
lotion,  1  to  40,  immediately  before  being  applied. 

To  fasten  down  the  margins  of  the  dressing  in  places  where  the  move- 
ments of  the  body  tend  to  loosen  the  dressing,  and  thus  to  allow  air  to 
penetrate  beneath  its  margins,  elastic  bandages  of  ordinary  elastic  webbing, 
or  of  pure  rubber  tissue  (Martin's  bandage)  serve  an  excellent  purpose  and 
in  some  regions,  as  the  groins,  axilla,  neck,  and  head,  are  indispensable. 
These  bandages  are  most  manageable  in  short  lengths,  and  should  vary  in 
width  from  one  to  two  and  a  half  inches,  according  to  the  size  of  the 
dressing,  or  the  region  of  the  body  to  be  dressed.  They  should  not  be 
put  on  too  tightly,  but  stretched  just  firmly  enough  to  keep  everything 

1  Codman  &  Shurtleff,  of  Boston,  furnish  these  various  materials  at  the  following 
prices:  Macintosh  cloth,  1  yard  wide,  per  yard,  $1.50  ;  heavy  gutta-percha  tissue,  32 
inches  wide,  per  yard,  $1.00;  thin  gutta-percha  tissue,  32  inches  wide,  per  yard,  50 
cents ;  paraffin  paper,  32  inches  wide,  per  yard,  6  cents. 


198  THE    TREATMENT    OF    WOUNDS. 

secure  against  the  movement  of  the  part,  or  the  shifting  position  of  the 
patient  (MacCormac). 


APPLICATION  OF   THE  DRESSINGS. 

THE  METHOD  OF  LISTER. — As  the  method  perfected  by  Mr.  Lister  was 
the  first  in  which  the  indication  for  protecting  wounds  from  contamination 
by  septic  dust,  and  for  keeping  their  discharges  free  from  putrefaction 
was  accepted  as  the  chief  end  of  treatment,  and  was  successfully  accom- 
plished, the  details  of  the  arrangement  of  the  dressings  adopted  in  this 
method  for  securing  continued  protection  after  the  arrest  of  the  haemor- 
rhage, the  cleansing  of  the  wound,  its  drainage,  and  the  apposition  of  its 
surfaces  had  been  accomplished,  claim  the  first  mention.  The  following  is 
Cheyne's  description  of  the  details  of  the  application  of  these  dressings 
("Antiseptic  Surgery,"  pp.  87-93): 

The  dressing  employed  is  the  carbolic  gauze  ;  and  to  prevent  the  irri- 
tation of  the  healing  edge  of  the  wound  by  the  carbolic  acid,  a  piece  of 
protective  is  interposed  between  the  gauze  and  the  wound.  This  protec- 
tive is  cut  a  little  larger  than  the  wound,  and  it  is  well  to  cover  the  but- 
tons with  a  little  bit  also,  in  order  to  prevent  the  threads  of  the  gauze 
from  becoming  entangled  in  them.  This  protective  need  not  extend  over 
the  orifice  of  the  drainage-tube,  as  its  essential  object  is  to  protect  the 
healing  part  from  the  irritation  of  the  carbolic  acid.  Outside  the  protec- 
tive a  piece  of  gauze  wet  in  the  carbolic  lotion  (1  to  40)  is  applied  so  as  to 
overlap  the  protective  in  all  directions.  The  reason  for  this  is  that  dry 
gauze  is  apt  to  receive  dust  on  its  surface  before  being  used,  while  at  the 
ordinary  temperature  of  the  atmosphere  but  little  carbolic  acid  is  given  off 
from  the  gauze,  certainly  not  enough  to  destroy  immediately  the  activity 
of  the  septic  particles  in  the  dust  But  if  the  piece  of  gauze  applied  next 
to  the  protective  be  moistened  in  the  1  to  40  solution,  this  dust  is  at  once 
deprived  of  septic  energy,  and  we  apply  over  the  wound  a  layer  of  pure 
and  powerfully  antiseptic  material  The  piece  of  wet  gauze  and  the  pro- 
tective go  by  the  name  of  the  deep  dressing  (Fig.  69).  This  deep  dress- 
ing may,  in  some  cases,  and  more  especially  where  catgut  stitches  and  cat- 
gut drains  are  used,  be  left  for  several  days  undisturbed.  If  the  deep 
dressing  be  thus  left  on,  it  must  be  remembered  that  the  deep  piece  of 
gauze  loses  all  its  carbolic  acid  very  soon,  and  that,  therefore,  it  must  be 
treated  as  a  wound — i.e.,  in  renewing  the  dressing  this  deep  part  must  be 


THE    LISTER   DRESSING. 

overlapped  in  all  directions  by  a  piece  of  wet  gauze,  and  that  again  by  a 
dressing  of  suitable  size. 

Having  arranged  the  deep  dressing  in  a  suitable  manner,  any  hollows 
which  exist  in  the  neighborhood  of  the  wound  are  filled  up  with  carbolic 
gauze,  and  special  masses  of  this  material  are  placed  where  the  greatest 
amount  of  discharge  is  expected.  Outside  this  a  large  gauze  dressing, 
consisting  of  a  piece  of  gauze  of  sufficient  size  folded  in  eight  layers,  be- 
neath the  outer  layer  of  which  is  placed  a  piece  of  macintosh  cloth,  is  ap- 
plied. The  size  of  this  dressing  varies  according  to  the  amount  of  dis- 
charge expected,  but  in  all  cases  it  must  extend  well  beyond  the  deep 


PIG.  69. — Protective  and  Deep  Dressing  applied  to  Wound  made  in  Excision  of  the  Hip-joint  (Cheyne). 

dressing  in  all  directions.  This  dressing  is  fixed  on  with  a  suitable  band- 
age of  gauze  or  ordinary  cheap  muslin.  The  dressing  is  pinned  round  its 
edge  to  the  bandage.  Care  must  be  taken  not  to  put  pins  through  the 
macintosh  at  any  part  except  at  its  edge.  To  prevent  the  edge  of  the 
dressing  from  becoming  separated  from  the  skin,  and  air  passing  into  the 
space  thus  formed,  the  edges  of  the  dressing  are  surrounded  with  an  elas- 
tic bandage,  put  moderately  on  the  stretch,  its  general  arrangement  vary- 
ing with  the  situation. 

As  a  rule,  the  dressing  ought  to  be  changed  entirely  on  the  following 
day,  the  deep  part  as  well  as  the  superficial.  It  is  well  to  change  the  deep 
dressing  in  order  to  see  that  none  of  the  stitches  are  too  tight,  and  that 
the  drains  are  acting  properly.  After  the  first  day  the  deep  dressing  need 
not  be  touched,  unless  the  patient  is  complaining  of  uneasiness,  or  unless 
the  surgeon  wishes  to  see  the  wound  for  the  purpose  of  removing  stitches 


200  THE   TREATMENT    OF    WOUNDS. 

or  drain.  If  the  deep  dressing  is  not  changed,  great  care  must  be  taken 
to  have  an  efficient  spray  playing  over  the  part 

In  changing  the  dressing  the  spray  is  used,  and  also  1  to  40  carbolic 
lotion,  in  which  a  piece  of  loose  gauze  and  protective  are  put  before  the 
dressing  is  begun.  The  elastic  bandage  is  first  removed,  and  then  the  pa- 
tient or  an  assistant  places  his  hand  over  the  centre  of  the  dressing  while 
the  bandage  is  being  cut,  so  as  to  prevent  the  dressing  being  lifted  up  and 
air  pumped  in.  Then  the  surgeon,  having  purified  his  fingers,  and  having 
turned  on  the  spray,  lifts  the  edge  of  the  dressing  carefully,  taking  care 
that  the  spray  passes  into  the  angle  between  the  dressing  and  the  skin. 
Having  removed  the  superficial  dressing,  he  again  dips  his  fingers,  and 
then  removes  the  deeper  parts  and  exposes  the  wound. 

If  nothing  is  wrong,  he  immediately  applies  fresh  protective  and  wet 
gauze,  and  then  washes  the  parts  round  about,  as  far  as  the  discharge  has 
extended,  with  1  to  40  carbolic  lotion.  The  edge  of  the  wound  is  not 
washed  or  exposed  to  the  action  of  the  spray  longer  than  is  absolutely  ne- 
cessary. A  fresh  dressing  is  applied  as  before  described. 

The  next  dressing  takes  place  on  the  following  day  at  visit,  if  there  is 
any  discharge  at  the  edge  of  the  dressing,  or  if  the  wound  feels  uneasy. 
The  rule  for  changing  the  dressing  is  :  Change  if  discharge  is  through  at 
the  visit  hour,  or  if  there  be  any  other  reason  for  it ;  if  not,  leave  the  dress- 
ing till  the  next  day  at  visit,  and  then  follow  the  same  rule. 

Never  leave  a  dressing  unchanged  longer  than  a  week.  By  that  time 
most  of  the  carbolic  acid  has  passed  off  by  evaporation,  and  therefore,  if 
the  discharge  once  came  to  the  edge,  putrefaction  could  spread  inward 
with  great  rapidity.  And  it  would  not  be  necessary  for  the  discharge  to 
appear  at  the  edge  in  order  to  have  putrefaction  of  the  wound,  for  the 
sweat  collecting  beneath  the  dressing  permits  the  multiplication  of  septic 
particles  in  it,  and  thus  they  may  reach  the  wound. 

THE  IODOFORM  DRESSING  OF  BILLROTH. — According  to  the  practice  of  Bill- 
roth,  of  Vienna,1  it  makes  little  difference,  in  most  cases,  what  kind  of 
antiseptic  protective  material  is  used  for  the  immediate  covering  of  wounds 
that  can  be  closed,  but  on  account  of  its  less  irritating  properties,  its  effect 
to  diminish  secretion,  and  its  more  permanent  and  intense  antiseptic  power, 
the  iodoform  gauze  is  preferable  to  the  carbolized  gauze.  The  iodoform 
dressings,  however,  have  their  greatest  usefulness  in  wounds  that  cannot 

1  Hacker :  Anleitung  zur  Antiscptischen  Wundbehandlung  nach  der  an  Prof.  Bill- 
roWs  Klinik  gebraucldichen  Meihode.  Wien,  1883. 


IODOPOBM    DRESSINGS.  201 

be  united,  in  wounds  of  mucous  cavities,  and  in  larger  wounds  in  which 
processes  of  decomposition  already  exist. 

Closed  wounds. — Superficial  wounds,  as,  for  example,  in  the  face,  though 
they  have  little  need  of  any  dressing  beyond  the  scab  formed  by  the  desic- 
cation of  the  slight  layer  of  blood  and  secretion  that  collects  upon  the  line 
of  their  union,  as  a  matter  of  security,  may  be  covered  with  iodoform  col- 
lodion l  or  iodoform  gauze. 

In  deeper  wounds,  no  iodoform  is  applied  to  the  wound  surfaces,  and 
no  "  protective  "  is  applied  over  the  line  of  suture.  The  advantage  of  an 
easy  removal  of  the  dressing  material  from  a  wound  covered  by  "  protect- 
ive," is  surpassed  by  the  advantage  of  the  drying  of  the  secretions  as 
they  come  in  contact  with  the  gauze,  and  by  the  more  immediate  effect  of 
the  iodoform  upon  the  secretions  as  formed.  The  sutures  ai*e  made  less 
irritating,  also,  as  evidenced  by  the  fact  that  suppuration  at  the  points  of 
entrance  and  exit  of  the  needle,  when  iodoform  is  used,  is  very  rare. 
Directly  upon  the  wound,  after  its  apposition  and  suture  has  been  effected, 
from  four  to  six  layers  of  absorbent  iodoform  gauze  are  laid,  of  sufficient 
width  to  extend  half  an  inch  beyond  the  margins  of  the  wound.  Over 
this  is  placed  one  or  more  layers  of  crumpled  carbolized  gauze,  and  over 
all  a  layer  of  smooth  carbolized  gauze,  or  absorbent  cotton,  or  ordinary 
purified  gauze.  The  whole  is  enveloped  in  a  layer  of  impermeable  mate- 
rial, and,  at  the  margins  of  the  dressing,  pads  of  absorbent  cotton  or  gauze 
are  placed  so  as  to  afford  compresses  over  the  impermeable  material  where- 
ever  special  pressure  seems  indicated.  The  fixation  of  the  dressing  is 
accomplished  by  a  common  roller  bandage. 

Open  ivounds. — No  other  dressing  will  give  such  uniformly  good  results 
in  the  treatment  of  open  wounds  as  the  iodoform.  Nor  is  any  method  of 
dressing  such  cases  so  simple  in  its  application,  or  requiring  such  infre- 
quent changes. 

Open  wounds,  after  being  cleansed,  are  to  be  simply  filled  with  absorb- 
ent iodoform  gauze.  In  irregular  cavities,  the  fn*st  layer  of  the  gauze  is  cut 
in  strips  and  introduced  into  all  fissures  and  compartments  ;  into  the  remain- 
ing cavity  layers  of  gauze  are  loosely  packed  till  the  space  is  filled  to  the 
level  of  the  integument.  A  double  layer  of  iodoform  gauze  is  then  placed 
upon  it  so  as  to  extend  over  the  margins  of  the  wound.  The  dressing  is 
completed  by  carbolized  gauze,  impermeable  material,  and  bandages,  ex- 

1  Iodoform  collodion  is  a  solution  of  iodoform  in  collodion  in  the  proportion  of  1 
part  to  10. 


202  THE    TREATMENT    OF    WOUNDS. 

actly  as  in  closed  -wounds,  except  that  no  firm  compression  is  to  be  pro- 
duced. Healing  takes  place  by  granulation  with  but  very  little  suppura- 
tion. The  dressing  may  be  left  undisturbed  for  from  eight  to  fourteen 
days. 

It  is  of  the  greatest  importance  that  every  corner  and  fissure  of  a 
wound  be  brought  in  contact  with  the  iodoform  gauze. 

Change  of  Dressings. — It  is  expedient  not  to  permit  the  dressings  to 
remain  unchanged  for  a  longer  period  than  eight  to  ten  days,  on  account 
of  the  eczematous  irritation  of  the  skin  which  the  gauze  and  the  retained 
perspiration  is  likely  to  excite,  if  left  unchanged  too  long,  notwithstanding 
the  antiseptic  properties  of  the  dressing  may  be  sufficient  for  a  much 
longer  time.  After  major  operations,  it  is  sometimes  desirable  to  change 
the  dressing  on  the  evening  of  the  same  day,  or  the  day  following,  on  ac- 
count of  the  saturation  of  the  dressing  by  haemorrhage.  If  the  oozing  is 
moderate,  it  may  suffice  to  renew  only  portions  of  the  dressing  the  first 
evening,  as  the  carbolized  gauze,  cotton,  and  impermeable  material,  and 
defer  the  complete  change  until  the  next  day.  As  long  as  no  secretions 
appear  on  the  surface  the  dressing  may  remain,  so  that  in  the  treatment  of 
very  large  wounds  that  may  require  three  or  four  weeks  for  healing,  the 
dressing  may  be  changed  only  two  or  three  times.  In  general,  however, 
the  dressing  will  be  renewed  in  six  to  eight  days,  the  time  when  the  drain- 
age tubes  and  deep  sutures  are  to  be  removed.  When  complete  union  by 
first  intention  is  not  secured,  the  drainage  tubes  must  be  left  in  place 
where  suppuration  exists,  to  be  gradually  shortened  before  their  final  re- 
moval. In  such  wounds  a  change  of  dressing  is  rarely  required  on  account 
of  abundant  secretions  ;  the  gauze  adhering  to  the  wound  may  remain, 
and  it  will  be  only  requisite  to  change  the  layers  of  carbolized  gauze  and 
of  cotton.  In  cases  where,  as  in  compound  fractures,  it  is  of  the  greatest 
importance,  for  the  formation  of  callus  and  for  the  rest  of  the  part,  that 
the  dressing  remain  as  long  as  possible,  it  may  remain  fourteen  days  or 
even  three  weeks,  provided  no  disturbance  manifests  itself.  The  openings 
left  by  the  drainage  tubes  will  require  a  longer  time  for  closure,  and  will 
leave  small  cicatrices. 

A  change  of  dressing  becomes  necessary  whenever  the  temperature 
rises  to  102°  F.,  and  above,  especially  when  connected  with  rigors.  It  is 
desirable  for  safety's  sake  at  any  time  when  the  dressing  is  abundantly 
saturated  with  blood.  When  the  dressing  is  changed,  the  drains  should 
be  injected  with  a  stream  of  water  to  see  that  they  are  not  clogged  ;  any 


TURF-MOULD   DRESSINGS.  203 

tension  of  the  sutures  may  be  moderated  by  the  removal  of  some  of  them. 
If  the  febrile  disturbances  do  not  disappear,  if  the  secretions  increase, 
assuming  a  suppurating  character,  with  a  bad  odor— a  rare  occurrence 
— the  dressing  must  be  changed  every  day,  or  every  second  day.  lodo- 
form  gauze  should  be  used  sparingly  on  account  of  the  danger  of  the 
toxic  effects  of  iodoform.  In  such  cases,  forming  an  exception  to  the 
general  rule,  the  wound  should  be  irrigated  with  a  strong  solution  of 
carbolic  acid  1-20,  or  with  a  solution  of  chloride  of  zinc  1-500.  In  an 
ordinary  change  of  dressing,  irrigation  and  pressure  to  remove  detritus  is 
not  used. 

If,  notwithstanding  the  injections,  fever,  anorexia,  and  general  weakness 
remain,  it  is  proof  that  antisepsis  has  failed.  It  becomes  necessary  then 
to  remove  the  sutures,  open  the  wound,  and  fill  its  cavity  with  iodoform 
gauze.  If  a  frequent  change  of  the  dressing  is  imperative,  some  other  anti- 
septic, as  acetate  of  alumina,  must  be  substituted  for  the  iodoform.  After 
the  wound  is  perfectly  pure,  the  process  of  healing  may  be  hastened  by 
approximating  the  edges  of  the  wound  by  secondary  sutures  of  silver  wire, 
or  strips  of  iodoform  or  adhesive  plaster  may  be  applied. 

As  a  rule,  the  iodoform  gauze  should  be  continued  only  for  two  or 
three  weeks,  until  a  good,  healthy,  granulating  surface  has  formed,  the 
final  cicatrization  of  which  will  be  hastened  by  the  use  of  zinc  or  boracic 
acid  ointment 

ESMAKCH'S  TUKF-MOTJLD  DRESSING. — This  is  used  in  the  following  man- 
ner, which  has  been  very  successful :  Bags  of  gauze  wrung  out  in  5  per 
cent  carbolic  solution  are  prepared  of  two  sizes,  5  and  10  square  inches 
respectively.  These  are  filled  with  turf-mould  (or  dust),  the  smaller 
bag  with  mould  containing  2^-  per  cent  of  iodoform,  which  is  laid  on 
the  wound  directly,  which  has  been  disinfected  with  either  carbolic  solu- 
tion (2f  per  cent),  zinc  chloride  (8  per  cent),  or,  at  most,  45  grains  of 
iodoform.  Over  this  is  laid  the  larger  bag,  the  mould  in  which  is  sat- 
urated with  5  per  cent  carbolic  solution.  The  whole  is  kept  in  place  by 
a  gauze  bandage. 

These  examples  which  have  been  detailed  will  suffice  to  illustrate  the 
method  of  applying  practically  the  principles  which  will  guide  the  surgeon 
in  the  use  of  any  of  the  absorbent,  antiseptic,  and  protective  dressings 
which  have  been  described.  In  the  chapters  on  antisepsis,  antiseptics,  and 
wound-cleanliness,  the  indications  to  be  met,  and  the  special  properties 
of  various  antiseptics  have  been  carefully  detailed.  The  judgment,  per- 


204  THE   TREATMENT    OF    WOUNDS. 

haps  simply  the  convenience  or  caprice,  of  the  surgeon  will  determine 
the  choice  of  individual  applications  in  many  cases.  All  other  things 
being  equal,  those  applications  which  are  the  simplest,  the  least  expen- 
sive, the  most  readily  obtained,  and  which  need  the  least  frequent  chang- 
ing, merit  adoption  for  general  use.  The  particular  indications  which 
special  wounds  present  will  be  considered  in  the  chapters  devoted  to 
those  wounds. 


CHAPTER  XL 

PROTECTION  AGAINST  DISTURBANCES  OF  HEALING— (CONTINTOD). 

REST. 

Position —  Compression — Immobilization — Wire-gauze  Splints — Plaster-of -Paris  Splints 
—  Shells  —  Encircling  Plaster-bandage  —  Fenestrated — Interrupted — Combined — 
Change  of  Dressings — Anodynes. 

REST,  as  nearly  absolute  as  possible,  is  of  great  importance  in  favoring  the 
undisturbed  and  rapid  healing  of  a  wound.  This  involves  protection  from 
motion  and  from  external  mechanical  violence,  the  control  of  muscular 
spasm,  and  every  means  which  will  tend  to  insure  quietude  and  comfort 
in  the  wounded  part  The  means  by  which  rest  is  to  be  obtained,  include 
Position,  Compression,  Immobilization,  Infrequent  and  Careful  Dressings, 
and  Anodynes. 

POSITION. 

That  position  should  always  be  selected  which  will  be  comfortable  to 
the  patient.  An  uncomfortable  position  provokes  general  restlessness  and 
local  muscular  spasm.  Attention  to  the  comfort  of  the  part  cannot  be  too 
carefully  regarded.  This  position  will  always  be  one  in  which  the  parts  are 
relaxed,  and  the  return  circulation  of  the  blood  to  the  heart  is  favored.  The 
limbs,  if  wounded,  should  be  slightly  flexed  and  elevated.  In  wounds  of 
the  lower  extremity  this  is  of  more  importance,  and  demands  more  care  in 
its  accomplishment.  The  foot  should  be  raised  to  a  higher  level  than 
the  knee,  and  the  knee  than  the  hip ;  in  cases  of  severe  wounds  the  limb 
should  be  swung  so  that  movements  of  the  trunk  should  not  disturb  the 
injured  limb.  The  relations  of  position  to  drainage  should  be  kept  in 
mind,  and  in  the  arranging  of  the  means  for  drainage,  whenever  possible, 
the  drains  should  be  so  placed  as  to  be  most  efficient  when  the  part  shall 
have  been  placed  in  the  position  of  the  greatest  comfort. 


206  THE   TREATMENT    OF    WOUNDS. 

COMPRESSION. 

Gentle,  uniform,  and  continuous  pressure  is  of  great  value  in  promot- 
ing rapid  repair  after  injury.  It  restrains  excessive  "active  hypersemia," 
limits  effusion,  and  promotes  absorption  of  effusions  already  present  When 
properly  applied  it  prevents  muscular  spasm,  and  thus  becomes  a  valuable 
auxiliary  in  securing  rest  to  the  part.  A  greater  and  more  methodical  ap- 
plication of  pressure  than  is  needed  for  maintaining  simple  apposition  of 
the  separated  parts  is  required  to  obtain  the  full  power  of  compression 
in  favoring  the  repair  of  a  wound.  Compression  should  be  smooth  and 
uniform,  gentle  but  firm,  while  any  constriction  is  carefully  avoided.  In 
most  cases  it  may  be  best  effected  by  surrounding  the  wounded  part  with 
layers  of  cotton  wool,  and  applying  compression  with  roller-bandages. 
The  wool  moulds  itself  exactly  to  the  limb,  and  by  its  elasticity  tends  to 
evenly  distribute  the  compression  exercised  by  the  bandage  and  to  keep 
the  pressure  continuously  uniform.  In  cases  of  wounds  of  the  limbs  the 
bandage  should  be  applied  first  at  their  distal  ends,  and  carried  up  evenly 
and  carefully  over  the  wounded  part,  and  above  it  for  some  distance. 
The  means  of  compression  will  also  be  important  elements  of  the  means  of 
immobilization,  in  the  consideration  of  which  the  value  of  the  compression 
itself  is  apt  to  be  lost  sight  of.  Experience,  however,  has  shown  that  im- 
mobilization without  methodical  compression  is  more  imperfectly  and 
slowly  efficient  in  promoting  repair  and  delaying  wound-disturbances  than 
when  both  are  combined.  Perfect  quiet  and  uniform  compression  are  the 
most  conspicuous  agents  which  can  reinforce  the  natural  reparative  energy 
of  a  part 

IMMOBILIZATION. 

Immobility  is  to  be  secured  by  the  judicious  application  of  splints, 
pads,  and  bandages.  A  splint,  whenever  applied,  should  assist  in  furnish- 
ing equable  and  uniform  compression  and  support,  as  well  as  fixation.  For 
this  purpose  the  various  forms  of  plastic  splints  offer  great  advantages  in 
many  cases  in  which,  as  in  penetrating  wounds  of  joints  and  compound 
fractures,  fixation  of  an  entire  limb  is  necessary.  Such  splints  accurately 
take  the  shape  of  the  parts,  forming  a  firm  mould  that  encases  and  fixes 
the  limb  without  pressing  unduly  at  any  one  point  As  a  result  such 
splints  are  borne  with  comfort,  and  thus  indirectly  contribute  still  more  to 
the  well-doing  of  the  wound.  It  is  unnecessary  to  attempt  to  enumerate 


WIEE-GAUZE    SPLINTS.  207 

the  many  different  materials  that  in  cases  of  emergency  may  be  used  as 
splints.  Wherever  a  wound  may  be  received  some  agent  that  will  serve  a 
temporary  purpose  for  immobilization  will  be  found.  In  lieu  of  better, 
bundles  of  straw  or  twigs,  or  layers  of  folded  newspapers  may  serve  an  ex- 
cellent purpose  as  splints.  Upon  the  battlefield  various  weapons  admit  of 
many  most  excellent  applications  as  splints.  Thin  strips  of  wood,  shaped 
according  to  the  requirements  of  the  part  to  which  it  is  to  be  applied,  and 
padded  with  cotton  wool,  will  always  be  found  to  make  most  excellent 
splints.  There  are  two  kinds  of  material,  however,  which  from  their  spe- 
cial advantages  as  agents  of  immobilization  in  the  treatment  of  wounds  de- 
serve more  extended  notice.  These  are  wire-gauze  and  plaster-of-Paris. 

Wire-gauze. — This  material  is  made  of  wire  from  one-twentieth  to  one- 
tenth  of  an  inch  in  diameter,  woven  into  a  fabric,  the  meshes  of  which  are 
from  three-tenths  to  five-tenths  of  an  inch  square,  or  the  length  of  the 
mesh  may  be  greater  than  the  width.  After  the  gauze  is  cleaned  with 
acid,  it  is  put  into  melted  zinc,  which  covers  the  wires  and  fastens  them 
quite  firmly  together  where  they  cross  each  other,  making  a  firm  and 
strong  structure.  The  material  is  a  common  article  of  commerce,  is  cheap, 
is  to  be  found  in  all  hardware  shops,  and  is  put  to  many  economic  uses. 
My  attention  was  first  called  to  the  value  of  this  material  for  surgical  pur- 
poses in  1873  when  I  entered  upon  duty  as  adjunct  surgeon  to  the  Long 
Island  College  Hospital,  where  it  had  been  introduced  by  my  immediate 
predecessor,  Prof.  J.  S.  Wight.  Its  surgical  uses  have  been  described  by 
Prof.  Wight,1  as  follows  :  In  the  first  place,  the  fabric  can  be  cut  into  any 
desired  shape  by  a  pair  of  tinsmith's  shears.  The  separate  wires  may 
be  cut  out  by  a  pair  of  cutting  pliers.  The  pieces  of  gauze  may  be  bent 
into  any  required  form  by  the  hands  of  the  surgeon ;  and  when  bent  it 
will  generally  have  enough  firmness  and  resistance  to  keep  its  form  under 
all  ordinary  circumstances.  It  is  very  light — having  the  same  extent  of 
surface,  it  is  lighter  than  wood,  tin,  zinc,  or  binder's  board,  used  for 
splints.  It  ventilates  the  part  to  which  it  is  applied  better  than  any  other 
splint  material  It  is  very  desirable  where  irrigation  is  needed  ;  it  is  non- 
absorbent.  At  any  time  it  can  be  removed,  disinfected,  and  reapphed 
with  facility.  It  may  be  strengthened  by  fastening  to  it  by  small  staples 
light  strips  of  wood.  It  may  be  used  to  strengthen  plaster-of-Paris  splints, 
particularly  when  they  are  to  be  fenestrated.  The  combination  of  qualities 

1  The  Surgical  Uses  of  Wire-cloth.  Proceedings  of  the  Medical  Society  of  the 
County  of  Kings,  January  1881,  p.  375. 


208  THE    TREATMENT    OF    WOUNDS. 

which  have  been  enumerated — its  cheapness,  the  readiness  with  which  it 
can  be  shaped  and  moulded  to  a  part,  its  lightness,  its  non-absorbent 
qualities,  and  the  perfect  freedom  with  which  its  open-meshed  interstices 
permit  the  passage  of  moisture  through  it,  make  it  a  material  of  great 
value  for  purposes  of  wound-dressings. 

Plaster-of-Paris. — Of  the  various  substances  that  have  been  used  while 
in  a  moist  and  pliant  condition  to  envelop  a  part,  a  firm  mould  of  which 
they  afterward  form  by  hardening,  plaster-of- Paris  has  proved  to  possess 
in  the  greatest  degree  the  qualities  needed  for  common  use.  It  is  gener- 
ally easily  and  quickly  procurable  ;  it  is  cheap  ;  its  manipulation  is  sim- 
ple ;  it  quickly  hardens  and  forms  a  firm  and  accurate  envelope  of  the 
part  to  which  it  is  applied,  so  as  to  insure  absolute  immobility  and  uniform 
compression  with  perfect  comfort.  It  is  porous,  and  so  does  not  prevent 
the  escape  of  the  natural  perspiration  from  the  parts  covered  by  it 
Fine  white  plaster  (dentist's  plaster)  that  has  recently  been  calcined,  is  to 
be  chosen  for  use  in  making  an  immobilizing  apparatus.  If  it  has  been 
exposed  to  moist  air,  it  will  have  absorbed  sufficient  moisture  to  prevent 
its  hardening  readily  and  firmly.  If  fresh  plaster  is  not  attainable,  the  old 
may  be  made  again  fit  to  use  by  reheating  it  For  this  purpose  it  will 
simply  be  necessary  to  heat  it  in  an  iron  pan  over  a  good  fire  for  half  an 
hour,  or  until  it  ceases  to  "bubble." 

The  part  to  be  immobilized  should  be  wrapped  with  a  layer  of  cotton 
wool — sheet  wadding — or  in  default  of  this,  by  strips  cut  from  a  woollen 
blanket  A  stout  thread,  or  bit  of  cotton  twine,  wound  in  a  rapid  spiral 
over  this  preliminary  layer  of  cotton  or  blanket,  will  be  convenient  in 
keeping  them  in  place  while  the  plaster  is  being  applied. 

Three  different  methods  may  be  used  in  applying  the  plaster. 

One  method  is  to  cut  strips  of  coarse  blanket  flannel,  crash  towelling, 
or  similar  strong,  open-meshed  material,  into  suitable  lengths  and  shapes, 
so  that  they  will  partially  envelope  the  part  like  a  cuirass,  as  in  Figs.  72 
and  73,  and  dip  them  into  plaster-of-Paris  when  mixed  with  water,  so  as  to 
have  the  consistency  of  a  rather  thick  cream.  The  cloth  strips  thus  im- 
pregnated are  then  applied  to  the  limb,  and  while  the  plaster  is  still  plastic 
are  secured  to  the  limb  by  roller  bandages.  As  many  layers  may  be  ap- 
plied as  may  be  thought  necessary  to  give  the  requisite  strength  to  the 
splint  The  Bavarian  splint  (Figs.  70  and  71)  is  made  by  fastening  two 
pieces  of  such  cloth  together  by  a  row  of  stitching  down  the  centre,  and 
pouring  the  plaster-cream  between  the  pieces. 


THE    BAVARIAN    PLASTER-SPLINT. 


209 


When  it  is  to  be  employed  the  layers  of  cloth  should  be  applied  to  the 
limb  so  that  the  row  of  stitching  is  at  the  nether  side  of  the  limb  ;  then 
the  innermost  layer  is  brought  up  about  the  limb  and  smoothly  adapted 
to  it,  its  edges,  meeting  in  front,  being  secured  with  pins  temporarily. 
Then  the  plaster  is  poured  thickly  over  the  outer  surface  of  this  layer,  and 


FIG.  70.  FIG.  71. 

Fig.  70. — Pieces  of  Cloth  as  shaped  for  applying  the  Bavarian  Splint  to  the  Leg  (Esmarcti). 
Fig.  71.— The  Bavarian  Splint  applied. 

upon  the  inner  surface  of  the  outer  layer,  being  uniformly  spread  over 
them  by  the  hand  of  the  surgeon.  The  outer  layer  is  then  to  be  brought 
up  to  the  first,  and  after  having  been  properly  moulded  to  the  limb  by  the 
hand,  is  confined  by  a  roller  bandage  until  the  plaster  has  hardened. 

It  will  then  be  found  that  there  has  been  made  a  splint  consisting  of 
two  lateral  halves,  connected  together  behind  by  a  cloth  hinge,  which  per- 
mits the  two  halves  of  the  splint  to  open  like  a  book  and  expose  the  in- 
jured parta  When  anterior  and  posterior  strips  (Fig.  72)  are  used,  there 

results  two  accurately  fitting  shells  (Fig.  73)  either  one  of  which  can  be 
14 


210 


THE    TREATMENT    OF    WOUNDS. 


lifted  off  to  facilitate  inspection  of  the  part,  while  it  is  still  supported  by 
the  other.  A  great  variety  of  forms  of  splints,  as  needed  for  special  loca- 
tions and  injuries,  can  be  made  from  strips  of  cloth  and  plaster  after  this 
method. 

The  following  practical  directions  for  the  preparation  of  these  splints 
are  by  MacCormac  ("  Antiseptic  Surgery,"  p.  188),  and  are  worth  heeding  : 
"  Dressers  seldom  know  the  best  way  to  prepare  plaster-of-Paris  for  use. 

It  is  often  made  too  thick,  and  sets  too  soon  ; 
or,  it  is  too  thin,  and  additional  plaster  is 
added  at  the  last  moment,  which  makes  the 
mixture  lumpy  and  unmanageable.  A  suffi- 
cient quantity  of  water  for  the  purpose  in  hand 
should  be  first  poured  into  a  basin,  and  then 
the  plaster  lightly  shaken  into  it,  handful  after 
handful,  or  spoonful  by  spoonful,  but  without 
stirring,  until  the  plaster  just  begins  to  float 
on  the  surface  of  the  water  ;  then  enough  of 
plaster  has  been  added,  and,  on  stirring,  it 
will  quickly  blend  with  the  water,  and  a  ho- 
mogeneous mixture,  of  the  proper  consistence, 
that  of  thick  cream,  will  be  the  constant  result. 
"  In  this  the  flannel  strips  are  dipped,  and 
they  will  take  the  mixture  better,  and  form 
a  stronger  and  more  durable  splint  if  they  have 
been  previously  wetted,  all  superfluous  water 

FIG.  72.-Shape  of  Anterior  and  Pos-    being  Wrung  Out." 

terior  Flannel   Strips,   for  application  rj^  Qecond  method  consists  in  the  applied 

to  Lower  Limb  from  Midtnigh  to  Toes 

(MacCormac).  tion  of  roller  bandages  whose  fabric  is  satu- 

rated with  the  plaster.  These  bandages  are  previously  prepared  by 
rubbing  into  their  interstices  the  dry  plaster  ;  when  required  for  use, 
the  bandages,  made  into  loose  rollers,  are  immersed  in  warm  water  for 
a  short  time,  until  bubbles  of  air  cease  to  escape,  when  they  are  at 
once  applied.  To  reinforce  the  bandages,  plaster-cream  can  be  smeared 
over  them  after  they  have  been  applied.  Ordinary  muslin  rollers  are  not 
well  adapted  for  use  as  plaster  bandages.  A  more  open-meshed  and  ab- 
sorbent fabric  is  needed.  The  experiments  of  Dr.  Nelson,1  of  Boston, 


1  Plastic  Splints  in  Surgery.     Annals  of  Anatomy  and  Surgery,  1882,  v.,  p.  170. 


THE    PLASTER-OF- PARIS    ROLLER.  211 

have  shown  that  the  cheap  bleached  cotton-cloth  used  for  printed  calico, 
if  used  before  it  has  received  the  dressing,  is  a  superior  fabric  for  plastic 
uses.  It  is  then  free  from  oil  and  is  absorbent.  It  has  the  right  texture 
to  take  up  plaster  and  retain  it.  It  gives  the  maximum  of  strength,  and 
when  applied  is  very  durable. 

The  impregnation  of  the  meshes  of  the  cloth  with  the  plaster  with  the 
hand  or  knife  produces  an  imperfect  and  uneven  result,  while  it  is  at  the 
same  time  a  dirty  and  disagreeable  process.  The  simple  method  suggested 


FIG.  73. — Anterior  Leg  Splint. 

by  Esmarch  ("  Handbook,"  p.  44)  affords  a  more  satisfactory  result  in  a 
most  convenient  manner.  It  is  to  put  the  end  of  the  bandage  through  a 
slit  in  an  upright  board  (Fig.  74),  in  front  of  which  the  plaster-of-Paris  is 
placed  ;  the  bandage  is  then  rolled  up  in  this  heap  with  the  fingers. 

The  third  method  consists  in  applying  bandages  of  open-meshed  fabric, 
as  gauze  or  mosquito-netting,  to  the  limb,  and  then  smearing  them  with 
the  plaster-cream,  adding  successive  layers  of  the  bandage  and  of  the  plas- 
ter until  a  sufficiently  strong  splint  is  built  up.  A  very  light,  firm  and 
tough  splint  can  thus  be  built  up.  It  is  a 
method  to  which  I  am  myself  very  partial. 

Where  there  are  open  wounds,  open- 
ings must  be  made  in  the  splint  by  which 
ready  access  to  the  wound  can  be  secured 
and  free  escape  of  the  secretions  may  take 
place  (Fig.  75).  These  are  best  made  as 

soon  as  the  plaster  has  hardened  sufficiently  to  be  cut  without  displace- 
ment or  crumbling.  The  material  can  then  be  cut  quite  easily  with  a 
strong  sharp  knife.  The  edges  of  the  fenestrum  and  the  adjacent  surfaces 
of  the  splint  can  be  readily  made  impermeable  to  any  secretions  that  may 
come  in  contact  with  them  by  brushing  them  over  with  melted  paraffine. 
When  the  size  of  the  opening  required  for  the  necessary  exposure  of  the 
wound  is  so  great  that  a  connecting  isthmus  of  sufficient  strength  is  not 
left,  the  splint  may  be  made  in  different  sections,  and  the  two  sections 
connected  together  by  metal  or  wooden  bars  (Fig.  76). 


THE    TREATMENT    OF    WOUNDS. 


Plaster-of-Paris  may  often  be  combined  to  excellent  purpose  with  other 
materials,  as  wood,  metal  strips  or  wire,  or  wire  gauze,  in  the  construction 
of  splints  for  special  purposes.  A  typical  example  of  this  is  seen  in 


FIG.  75.— Windowed  Plaster  of-Paris  Bandage;  (EsmarcK). 

Esmarch's  plaster-of-Paris  suspension  splint  for  excision  of  the  wrist,  which 
w  a  combination  of  a  wooden  or  wire  splint  (Fig.  77),  a  wire  suspension 
bar  (Fig.  78),  and  an  interrupted  plaster  splint  The  wooden  splint  is 


FIG.  76.— Interrupted  Plaster-of- Paris  Bandage,  with  Iron  Hoop  Connecting  Bar'  (Enmarch). 

very  narrow  at  the  wrist,  bent  to  a  right  angle  at  the  elbow,  and  provided 
with  a  hole  for  the  internal  condyle  of  the  humerus.  The  arm  is  placed 
upon  the  splint,  which  is  padded  with  cotton  wool  and  bandaged  with 


PLASTER-OF-PARIS    SPLINTS.  213 

plaster-of-Paris  rollers.  Finally,  after  the  suspension  bar  has  also  been 
bandaged  on  with  plaster-of-Paris  rollers,  the  arm  is  suspended  by  a  rope 
and  pulleys,  as  in  Fig.  79.  One  of  the  merits  of  plaster-of-Paris .  splints, 
as  well  as  of  plastic  splints  in  general,  is  the  readiness  with  which  they  are 
suspended,  and  thus  facilitate  the  movements  of  the  patient  without  en- 
dangering disturbance  of  the  wound  to  the  degree  that  is  unavoidable 


FIG.  77. — Wooden  Portion  of  EsmarcK's  Suspension  Splint  for  Excision  of  the  Wrist. 

when  the  wounded  member  lies  on  an  immovable  surface.  The  limb, 
after  having  been  encased  in  the  splint,  should  be  swung  by  pieces  of  rub- 
ber tubing  or  bands,  passed  around  it  at  suitable  distances  from  each  other 
and  tied  to  a  bar  above  (Fig.  80). 

The  removal  of  a  plaster  bandage  may  be  accomplished  best  by  using  a 
suitable  saw  for  dividing  it.     A  large-sized  Hey's  saw  makes  a  very  con- 


FIG.  78. — Wire  Suspension  Bar. 

venient  instrument  to  be  used  for  this  purpose.  The  saw  devised  by 
Hunter,  of  Philadelphia  (Fig.  81),  is  an  excellent  model.  It  is  necessary 
that  the  teeth  should  be  widely  set,  so  that  a  wide  groove  may  be  cut  in 
the  bandage  for  the  free  passage  of  the  saw.  A  powerful  pair  of  shears, 
with  one  blade  flattened  so  as  to  be  insinuated  beneath  the  splint,  will 
suffice  to  slit  up  many  splints.  Fig.  82  shows  the  original  model  of 
Seutin,  which  has  not  since  been  improved  upon. 


214 


THE   TREATMENT    OF    WOUNDS. 


SUBSEQUENT  DRESSINGS. — Too  early  and  too  frequent  interference  with  a 
wound  may  become  an  obstacle  to  the  highest  degree  of  success  in  secur- 
ing its  undisturbed  healing.  Infrequent  dressing  is  eminently  conducive 
to  that  absolute  rest  which  is  to  be  kept  in  view  in  whatever  method  of 


FIG.  79.— Esmarch'b  Plaster-of-Paris  Splint  for  Excision  of  the  Wrist,  Applied  and  Suspended. 

treatment  is  adopted.  When  the  first  dressing  of  the  wound  has  been 
conducted  in  accordance  with  the  principles  of  rational  wound-treatment 
which  have  been  described  ;  when  the  bleeding  has  been  carefully  and  per- 


Fio.  80.— Fenestrated  Plaster-of-Paris  Splints  Suspended  (J.  D.  Bryant). 

manentiy  arrested,  the  wound-surfaces  and  recesses  perfectly  cleansed  and 
rendered  aseptic,  the  retention  of  secretions  and  debris  provided  against 
by  efficient  means  of  drainage,  the  divided  surfaces  brought  together  as 


AFTER-CARES. 


215 


far  as  possible  and  retained  in  apposition,  and  adequate  means  of  protec- 
tion against  septic  infection,  mechanical  injury,  and  motion,  whether  pas- 
sive or  active,  has  been  provided,  its  rapid  and  undisturbed  healing  will 
certainly  take  place,  with  but  few  changes  of  dressings  necessitated.  The 
after-cares  from  the  surgeon  will  be  limited  to  a  watchful  oversight  of  the 
means  of  protection  and  immobilization,  of  drainage  and  apposition,  that 
have  been  employed,  that  they  be  removed,  substituted,  or  reinforced  by 
others  as  soon  as  they  are  no  longer  called  for,  or  have  become  inefficient 
The  course  of  the  wound  in  its  repair  is  largely  dependent  upon  the  per- 


Fio.  81. — Hunter's  Plaster-Bandage  Saw. 

fection  which  each  one  of  the  great  indications  for  treatment  which  have 
been  dwelt  upon  may  have  been  met  at  the  first.  It  has  been  seen  that 
the  most  frequent  cause  of  wound-disturbance,  as  well  as  the  cause  of  the 
most  perilous  of  the  disturbances  that  may  complicate  wounds,  is  the  con- 
junction of  the  agents  and  the  subjects  of  decomposition.  The  prevention 
of  access  of  the  one,  and  the  removal,  as  fast  as  formed,  of  the  other,  there- 
fore constitute  the  two  great  commandments  of  the  law  of  wound-repair, 
each  of  which,  equally,  every  one  who  undertakes  to  treat  a  wound  must 
comply  with  to  the  best  of  his  ability,  if  he  would  acquit  himself  of  re- 


PIG.  82. — Seutin's  Plaster  Shears. 

proach  for  the  results  of  disturbance  that  may  supervene  in  the  progress  of 
the  wound.  Inflammatory,  erysipelatous,  gangrenous,  or  septicsemic  com- 
plications attacking  wounds  can  no  longer  be  regarded  as  unfortunate  and 
unavoidable  accidents,  but  must  be  regarded  as  the  results  of  errors  or 
failures  in  the  treatment  which  the  wounds  have  received.  It  is  especially 
in  the  treatment  of  fresh  wounds  that  the  responsibility  of  the  surgeon  is 
the  greatest,  since  "  the  fate  of  the  wounded  man  depends  almost  entirely 
upon  the  application  of  the  first  dressing."  When  a  neglected  wound,  or 


216  THE    TREATMENT    OF    WOUNDS. 

one  already  manifestly  septic,  comes  under  the  care  of  the  surgeon,  his  re- 
sponsibility is  less  than  in  the  case  of  fresh  wounds,  but  his  duty  still  is 
manifestly  to  persistently  endeavor  to  convert  the  dangerous  septic  wound 
into  one  that  is  aseptic,  even  if  the  trial  be  made  in  vain. 

"When  the  first  dressing  of  a  wound  has  been  successfully  and  perfectly 
accomplished,  it  may  not  need  to  be  disturbed  for  some  days;  in  some 
cases,  as  has  been  mentioned  in  connection  with  special  methods  of  protec- 
tive dressing,  ten  and  fourteen  days  may  be  permitted  to  pass  without  re- 
moving the  dressings,  by  which  time  the  wound  may  be  found  to  be  quite 
or  nearly  healed.  In  all  cases  where  the  external  protective  dressings  re- 
main dry,  as  long  as  the  wound  remains  free  from  pain  and  fetor,  and 
there  is  no  acceleration  of  the  pulse  nor  elevation  of  the  temperature,  the 
dressings  may  remain  undisturbed.  The  use  of  the  thermometer  as  a 
guide  to  the  surgeon  is  an  invaluable  aid,  a  rise  of  temperature  being  a 
sign  that  should  invite  immediate  examination  of  the  wound  for  the  begin- 
nings of  possible  disturbances  there,  although  it  may  also  be  occasioned 
by  intercurrent  troubles  in  other  parts  or  organs  of  the  body. 

It  is  impossible  to  fix  arbitrarily  the  periods  for  the  renewal  of  the 
dressings.  Each  case  must  be  a  law  to  itself,  according  as  the  special  con- 
ditions which  it  may  present  may  determine.  The  indications  which  the 
drainage,  the  sutures,  the  compresses,  the  protective  appliances  may  pre- 
sent have  been  sufficiently  set  forth,  as  to  the  principles  that  govern  their 
use,  in  the  various  sections  already  devoted  to  their  consideration. 

In  the  changing  of  the  dressings,  and  indeed  in  all  the  manipulations 
required  about  the  wound,  the  utmost  gentleness  should  be  used,  coupled 
with  a  deliberate  speed  that  is  possible  only  when  nothing  is  done  without 
a  purpose,  and  every  preparation  for  accomplishing  that  purpose  has  been 
made  beforehand.  When  splints  are  applied  for  purposes  of  immobiliza- 
tion, they  should  be  so  applied  that  they  shall  not  interfere  with  the  re- 
moval of  the  immediate  dressings  of  the  wound  when  necessary,  in  order 
that  no  necessity  may  arise  for  the  premature  removal  of  the  splints. 

ANODYNES. 

The  various  preparations  of  opium,  by  the  relief  of  pain,  and  the  feel- 
ing of  general  well-being  and  comfort  that  they  create,  by  their  tendency 
to  quiet  muscular  spasm,  and  to  steady  the  heart's  action,  may  contribute 
in  an  important  degree  toward  securing  the  desired  rest  for  a  wound. 


ANODYNES.  217 

They  should  be  given  in  small  and  often-repeated  doses,  according  as  pain, 
restlessness,  irritable  pulse,  or  muscular  twitching  may  demand  for  their 
control  When  an  anaesthetic  has  been  given,  as  in  surgical  operations, 
the  administration  of  an  opiate  by  suppository  introduced  into  the  rectum, 
or  hypodermically,  should  be  made  while  the  patient  is  yet  under  the  in- 
fluence of  the  anaesthetic. 


CHAPTER  XII. 

THE  BELIEF  OF  DISTUBBANCES  OF  HEALING— INFLAMMATION— 
GANGBENE— EBYSIPELAS— SEPTIO&MIA. 

Treatment  of  Inflammation — Opening  tJie  Wound — Incisions— Removal  of  Foreign 
Bodies — Position — Compression — Reduction  of  Heat— Cold  Compresses — Evaporat- 
ing Lotions— Irrigation — Immersion — Ice-bags— Cold  Water  Coils — Relaxation  of 
Vessels — Abstraction  of  Blood — Interrupting  tlie  Blood-supply — Resume — Treat- 
ment of  Gangrene  -Incisions— Continuous  Antiseptic  Irrigation — Stimulants — 
Treatment  of  Erysipelas — Antiseptics — Subcutaneous  Injections  of  Carbolic  Acid 
— Superficial  Applications — Naphthalin — Tonics  and  Stimulants— An tiphlogis- 
tics — Treatment  of  Septicaemia — Local  Disinfection — General  Treatment. 

INFLAMMATION. 

THE  treatment  of  an  inflamed  wound  must  be  directed  both  to  the  removal 
of  the  cause  of  the  inflammation  and  to  the  relief  or  mitigation  of  the  con- 
ditions that  attend  it,  or  result  from  it.  The  substitution  of  destructive 
inflammation  for  the  constructive  processes  that  make  for  the  repair  of  a 
wound  never  takes  place,  except  as  the  consequence  of  defects  either  of 
wound-cleanliness,  or  of  wound-protection,  or,  more  frequently,  of  both, 
hence  the  first  duty  of  the  surgeon,  when  in  the  presence  of  an  inflamed 
wound,  is  to  seek  for  its  causes  and  to  address  himself  first  to  their 
removal 

"With  but  few  exceptions  an  inflamed  wound  is  a  septic  wound,  and 
the  cause  of  the  inflammation  is  the  irritation  of  the  products  of  decom- 
position of  retained  secretions.  It  is,  accordingly,  those  wounds  in  which 
the  retention  of  secretions  is  most  difficult  to  prevent,  as  in  wounds  of 
joints  and  other  cavities,  wounds  leading  down  to  fractured  bones,  and 
deep,  irregular-punctured  wounds,  that  severe  inflammation  is  most  fre- 
quently met  with. 

To  give  free  vent,  therefore,  to  all  wound-secretions  that  may  have 
been  retained  is  the  first  thing  to  be  attended  to  in  the  treatment  of  such 
a  wound.  This  may  require  nothing  more  than  the  cutting  of  a  stitch,  so 


TREATMENT  OF  INFLAMMATION.  219 

that  the  natural  gaping  of  the  .wound  may  suffice  for  the  required  vent,  or 
ifc  may  require  counter-incisions  and  the  use  of  drains. 

Whatever  means  the  special  conditions  of  the  parts  may  make  neces- 
sary should  be  thoroughly  and  systematically  employed  until  ample  pro- 
vision for  the  entire  flowing  away  of  the  secretions  as  fast  as  formed  has 
been  secured.  "  In  all  spreading  and  diffuse  inflammations,  incision  is 
the  remedy  of  paramount  utility,  because  death  of  subcutaneous  tissue 
occurs  early — sometimes,  indeed,  as  the  initial  lesion  of  the  case — and, 
until  an  avenue  of  escape  is  provided  for  the  sloughs,  pus  formation  tends 
to  advance  progressively  beneath  the  skin,  where  it  is  liable  to  be  attended 
by  indefinite  destruction  of  tissue.  When  timely  and  sufficiently  ample 
openings  have  been  provided,  the  destructive  process  is  in  most  instances 
arrested  at  once.  Incisions  save  the  integument,  which  would  otherwise 
be  destroyed  by  the  spontaneous  formation  of  gangrenous  patches — a  re- 
sult which,  without  this  remedy,  is  almost  inevitable.  In  this  way,  in- 
deed, both  the  necessity  and  the  great  value  of  early,  free,  and  bold 
incision  is  demonstrated."1 

Mechanical  irritation,  motion,  and  premature  use  of  a  wounded  part 
may  provoke  inflammation  by  preventing  or  breaking  down  adhesions, 
inflicting  mechanical  violence  upon  tender  tissues,  interfering  with  repair, 
and  thus  presenting  anew  the  conditions  in  which  septic  changes  may  be- 
come rife.  The  search  for  and  removal  of  foreign  substances  that  may 
have  been  left  in  a  wound,  as  splinters  of  wood,  pieces  of  glass,  rusty 
nails,  bits  of  clothing,  detached  pieces  of  bone,  etc.,  must  not  be  over- 
looked in  cases  where  their  possible  presence  may  be  the  cause  of  the 
inflammation. 

When  the  causes  of  the  inflammation  have  been  removed,  all  those 
means  by  which  perfect  rest  of  the  part  can  be  secured  become  of  the 
greatest  importance.  The  part  must  be  placed  in  an  elevated  and  com- 
fortable position,  and  must  be  immobilized.  Then  may  be  used  such 
other  means  to  relieve  or  mitigate  the  pain,  heat,  and  swelling  of  the  part, 
and  to  overcome  the  vascular  congestion  upon  which  they  depend,  as  the 
conditions  of  the  wound  and  the  judgment  of  the  surgeon  may  indicate  as 
needful  and  practicable.  The  means  available  for  this  purpose  act  either 
by  compressing  the  swollen  tissues,  reducing  the  heat,  relaxing  the  ves- 
sels, abstracting  blood,  or  interrupting  the  blood-supply. 

COMPRESSION. — The  practice  of  compression  with  immobilization  is  at- 

1  Van  Buren:  International  Encyclopaedia  of  Surgery,  i. ,  p.  151. 


220  THE    TREATMENT    OF    WOUNDS. 

tended  with  the  most  marked  advantage  .in  the  treatment  of  inflamed 

» 
wounds.     All  that  has  been  said  with  reference  to  their  use  as  protective 

measures  to  healing  wounds  applies  with  yet  more  force  to  an  inflamed 
wound.  The  compression  must  be  even  and  continuous,  and  must  be  so 
applied  as  to  avoid  any  constriction.  Pain  and  strangulation,  with  gan- 
grene, may  result  from  attempts  at  circular  compression  in  which  every 
part  from  its  distal  extremity  upward  is  not  equally  compressed.  Properly 
applied  compression  is  attended  with  comfort,  and  whenever  it  produces 
discomfort  the  means  of  compression  should  be  rearranged  or  removed  al- 
together. An  elastic  roller  bandage  of  pure  rubber  (Martin's  bandage) 
can  be  used  to  make  compression  with  very  great  advantage,  and  may  be 
adapted  to  every  region  of  the  body.  Rollers  of  soft  cotton  cloth,  or  of 
flannel,  with  layers  of  cotton  wool,  enveloping  the  inflamed  part,  may  be 
used  for  making  pressure.  Compressed  sponge,  confined  by  a  bandage, 
and  then  supplied  with  water,  may  be  made  the  agent  of  strong  and  elas- 
tic pressure  by  its  tendency  to  swell.  Bags  of  water,  or  of  other  sub- 
stances that  will  permit  an  even  adaptation  of  their  surface  to  that  of  the 
inflamed  part,  may  be  laid  upon  inflamed  parts  so  as  to  exert  uniform 
compression. 

THE  REDUCTION  OF  HEAT. — The  judicious  use  of  cold,  locally  applied, 
is  of  especial  value  in  antagonizing  the  tendency  to  the  excessive  active 
hyperaemia  which  marks  the  earlier  phases  of  inflammatory  action.  It  ab- 
stracts heat,  constringes  the  vessels,  and  acts  as  a  local  sedative.  Its 
power  to  diminish  vascular  excitement  may  be  pushed  to  such  an  extreme 
that  deficient  nutrition  of  the  parts  to  which  it  is  applied  may  be  pro- 
duced, and  deficient  repair,  even  local  death,  result.  Its  use  should  be 
confined,  therefore,  to  the  control  of  acute  inflammatory  conditions,  or  as 
an  application  to  wounded  parts  in  which  inflammation  is  both  prone  to 
occur  and  to  be  followed  by  disastrous  consequences,  as  in  wounds  of 
joints  and  of  the  head.  Cold  should  be  so  applied  as  to  maintain  a  con- 
tinuously uniform  low  temperature,  for  when  applied  intermittently  each 
application  is  followed  by  more  or  less  vascular  reaction  which  disturbs 
the  repair  of  the  wound. 

Cold  Compresses. — Cold  may  be  applied  by  enveloping  the  part  in 
compresses  wrung  out  in  cold  water,  the  compresses  being  frequently 
changed  before  they  have  become  warmed.  This  is  apt  to  disturb  the  in- 
jured part,  and  is  likely  to  be  neglected,  so  that  it  is  an  unreliable  and 
objectionable  method,  though  the  one  most  frequently  adopted. 


APPLICATION    OF    COLD. 


221 


Evaporating  Lotions. — Compresses  may  also  be  wetted  with  a  dilute 
alcoholic  lotion,  the  rapid  evaporation  of  the  spirit  sufficing  to  cool  the 
parts.  Lotions  containing  a  mixture  of  equal  parts  of  ammonium  chloride 
vsal  ammoniac)  and  potassium  nitrate  (saltpetre)  lower  in  a  marked  de- 
gree the  temperature  of  parts  to  which  they  are  applied.  A  strength  of 
half  an  ounce  of  each  salt  to  the  quart  of  water  is  the  proportion  most 
frequently  used. 

Irrigation. — Continuous  cold  may  be  applied  to  a  part  by  arranging  a 
vessel  of  cool  water  above  it  so  that  a  constant  dripping  of  the  water  upon 
it  may  be  secured  (Figs.  83  and  84).  The  part  should  first  be  covered  by 


Pio.  83. -^Irrigation  (tt»march). 

a  piece  of  cloth  large  enough  to  extend  upon  the  integument  several  inches 
beyond  the  wound,  upon  which  the  water  from  the  irrigator  shall  fall  and 
then  be  diffused.  The  evaporation  of  the  water  from  the  compress  is  quite 
rapid,  and  increases  greatly  the  cooling  effect  of  the  irrigation,  so  that  it  is 
not  necessary  to  employ  water  of  a  very  low  temperature.  The  water  as  it 
runs  away  should  be  caught  upon  an  inclined  plane  (Fig.  83),  or  upon 


222 


THE   TREATMENT    OF    WOUNDS. 


some  -waterproof  material  beneath  the  limb  (Fig.  84)  and  guided  into  a 
receptacle  below.  The  needful  apparatus  for  irrigation  may  be  extempor- 
ized from  very  simple  materials.  A  common  wooden  or  tin  pail,  a  bottle 
with  the  bottom  knocked  out,  an  empty  fruit-can,  a  wash-basin,  a  cup, 
anything  that  will  hold  water,  and  any  material  that  will  absorb  or  convey 
water  suffices.  The  water  may  be  conveyed  by  making  a  siphon  of  a  bit  of 
rubber  tubing  (Fig.  83),  or  glass  tubing  (Fig.  84)  or  out  of  a  piece  of 


Flo.  84.— Irrigation  (Esmarch). 

candle-wicking  or  similar  absorbent  fabric.  Tubes  may  be  inserted  into 
the  bottom  of  the  vessel  containing  the  water,  and  the  amount  of  the  flow 
regulated  by  the  use  of  suitable  plugs  in  these  outlet  tubes. 

Immersion. — Wounds  of  the  extremities  may  be  immersed  in  cold 
water,  suitable  vessels  being  provided  in  which  the  inflamed  member  may 
be  laid.  A  very  low  temperature  is  not  needed  for  producing  energetic 
reduction  of  temperature.  The  frequent  addition  of  cool  water  to  keep 


ICE-BAGS.       COLD    WATER    COILS.  223 

the  temperature  of  the  bath  down  to  the  desired  point  will  require  watcn 
ful  care. 

Ice-bags. — Rubber  bags  (Fig.  85),  or,  when  they  are  not  accessible, 
bladders,  may  be  partly  filled  with  pounded  ice  and  be  laid  upon  a  part. 
This  method  is  particularly  convenient  for  the  application  of  cold  to  the 
head  and  to  the  joints.  If  the  direct  application  of  the  ice-bag  is  too  cold, 


PIG.  85.— Ice-bag  (EsmarcJi). 

layers  of  cloth  may  be  laid  between  the  ice-bag  and  the  part.  An  ice-bag 
may  be  securely  closed  by  wrapping  its  closed  mouth  about  a  wooden  disc 
or  large  cork,  as  in  Fig.  85,  and  tying  it  by  a  tape. 

Cold  Water  Coils. — Cold  may  be  continuously  applied  to  any  part  of 
the  surface  of  the  body  by  placing  upon  them  mats  formed  of  rubber 
tubing  coiled  to  the  requisite  size  and  shape,  the  coils  being  secured  by 
wire  tape,  and  by  passing,  either  by  fountain  or  siphon  action,  a  continu- 
ous current  of  cold  water  through  the  tubing  from  a  reservoir  placed  at  a 
convenient  height.1  Similar  mats  may  be  made  of  soft  metal  (Leiter's 
tubes).  The  extremities  may  be  encircled  by  spiral  turns  of  tubing 

1  W.  M.  Chamberlain  :  The  Uses  of  Rubber  Tubing  in  the  Therapeutics  of  Reduc- 
tion of  Body  Temperature.     The  Medical  "Record,  April  29,  1882,  p.  469. 


224 


THE   TREATMENT    OF    WOUNDS. 


through  which  the  water  may  flow.    Fig.  86,  from  Esmarch's  "Handbook," 
shows  a  forearm  thus  encircled  by  a  tube,  one  end  of  which  is  placed  in  a 


Fio.  86.— Cooling  Coil  (Enmarch). 


vessel  filled  with  ice-water,  while  the  other,  hanging  down,  discharges  the 
current  into  an  empty  pail.     Fig.  87  illustrates  the  application  of  the  cold 


Fio.  87.— Cooling  Coil  (Otis). 

water  coil  to  the  penis. '     The  coils  of  tubing  are  retained  in  place  by  a 
band  of  cotton  or  linen  cloth. 

THE  RELAXATION  OF  VESSELS. — Warmth  and  moisture  produce  a  soothing 

1  P.  N.  Otis :  The  Cold  Water  Coil  in  Inflammation  of  the  External  Male  Genital 
Apparatus.     The  Medical  Record,  January  9,  1875,  p.  19. 


POULTICES.       BLOOD-LETTING.  225 

and  relaxing  effect  upon  an  inflamed  part  directly  opposite  to  that  of  cold. 
They  promote  dilatation  of  the  vessels  and  thus  relieve  tension  by  enlarg- 
ing the  calibre  of  the  vessels  through  which  the  blood  is  crowding.  They 
favor  exudation  and  thus  relieve  the  congested  vessels.  They  relieve  pain 
and  thus  diminish  the  effect  of  reflex  irritation.  Moist  heat  may  be  ap- 
plied by  compresses  wrung  out  in  hot  water — fomentations — by  poultices 
and  by  immersion  in  hot  water.  The  compresses  and  the  poultices  should 
be  covered  over  by  a  layer  of  impermeable  material,  as  oiled  silk  or  rubber 
tissue,  to  retain  the  heat  and  moisture  and  lessen  the  frequency  with  which 
the  application  requires  renewal.  For  poultices  any  substance  capable  of 
being  reduced  to  a  soft  mushy  consistence  with  hot  water  may  be  em- 
ployed, but  on  account  of  the  general  facility  of  its  management  and  the 
length  of  time  that  it  retains  its  heat  and  moisture,  ground  flaxseed  is  to 
be  preferred.  Poultices  should  not  be  made  so  thick  as  to  be  burdensome 
by  their  weight,  nor  should  they  remain  unchanged  for  a  longer  period 
than  six  hours.  Immersion  in  hot  water  is  the  most  beneficial  method  of 
procuring  vascular  relaxation,  and  is  to  be  chosen  whenever  practicable. 
It  may  contribute  likewise  to  drainage  and  to  wound  cleanliness. 

THE  ABSTRACTION  OF  BLOOD. — Local  bleeding  may  have  a  very  benefi- 
cial effect  upon  an  inflammation  by  the  relief  of  tension  which  it  produces 
upon  the  congested  tissues  and  the  over-distended  vessels.  It  may  be  ob- 
tained by  scarifications,  by  incisions,  by  scarifications  and  cups,  and  by 
leeches.  The  bleeding  which  may  attend  the  incisions  required  for  the 
more  free  drainage,  and  for  the  relief  of  tension  in  inflamed  parts  is  of  value 
in  immediately  relieving  the  congestion  caused  by  previous  conditions. 

THE  INTERRUPTION  OF  THE  BLOOD-SUPPLY. — The  attempt  to  diminish  the 
amount  of  blood  supplied  to  an  inflamed  part  is  a  logical  result  of  the  re- 
cognition of  the  fact  that  the  active  afflux  and  undue  retention  of  blood  in 
the  part  is  the  most  prominent  factor  in  the  distress  and  damage  which  an 
inflamed  part  suffers.  Against  this  active  hypersemia  most  of  the  remedial 
measures  which  have  been  used  have  been  directed.  Position,  compres- 
sion, cold,  and  blood-letting  have  been  seen  to  be  of  benefit  either  by  pre- 
venting the  blood  from  going  into  a  part,  or  by  removing  it  from  it.  This 
may  be  yet  more  effectually  accomplished  by  cutting  off  the  main  stream 
of  blood  from  the  engorged  tissues,  by  which  device  the  veins  are  left  of 
their  original  calibre  to  drain  away  the  superabundant  blood,  while  the 
volume  and  force  of  the  arterial  current  are  greatly  diminished.  As  the 

result,  the  over-distended  capillaries  soon  recover  their  normal  calibre,  and 
15 


226  THE    TREATMENT    OF    WOUNDS. 

the  ordinary  processes  of  nutrition  and  repair  are  re-established.  Inter- 
ruption of  the  blood-supply  may  be  accomplished  by  the  various  means 
•which  have  been  discussed  in  connection  with  the  arrest  of  haemorrhage 
(Chapter  VL),  viz. :  forced  flexion,  compression  of  the  main  artery  by 
means  of  the  finger,  tourniquet  or  a  weight,  acupressure,  and  ligation. 

Forced  flexion  is  particularly  applicable  to  the  treatment  of  inflamed 
wounds  of  the  forearm  and  hand,  and  is  easily  and  well  combined  with  the 
means  of  elevation,  compression,  and  immobilization.  The  interruption  of 
the  current  through  the  main  trunks  of  the  lower  extremity  is  better  ac- 
complished by  the  ligature.  As  has  been  pointed  out  by  Mr.  Maunder,1  if 
compression  is  used  to  temporarily  interrupt  the  current,  and  for  any  rea- 
son should  be  relinquished  too  soon,  the  blood  would  then  not  only  pass 
to  the  inflamed  spot  through  the  enlarged  smaller  vessels,  but  also  through 
the  main  channel,  and  thus  an  additional  and  injurious  supply  would  re- 
sult The  gravity  of  the  proposed  operation  of  ligation  will  cause  this 
means  of  controlling  inflammation  to  be  resorted  to  only  in  cases  of  de- 
structive and  excessive  inflammation.  For  the  first  definite  formulation  of 
the  indications  for  the  use  of  ligation  of  the  main  artery  of  supply,  as  a 
means  of  arresting  acute  traumatic  inflammation,  and  for  its  practical  de- 
monstration by  a  series  of  cases,  the  profession  is  indebted  to  Dr.  H.  F. 
Campbell,  of  Georgia,  under  whose  direction,  in  1862,  in  the  military  hos- 
pitals of  Richmond,  Va.,  ligation  of  the  femoral  artery  in  four  cases,  and 
of  the  brachial  in  three  cases,  was  performed  for  the  arrest  of  violent  and 
uncontrollable  inflammation.  In  all  these  cases  the  pain,  the  swelling,  and 
turgescence  were  almost  immediately  relieved,  and  the  most  remarkable 
improvement  was  soon  seen  in  the  character  of  the  discharges.8  Six  of 
these  cases  were  reported  by  him  in  his  chapter  on  the  ligation  of  arteries, 
in  the  "  Manual  of  Military  Surgery,"  published  by  the  Surgeon-General 
of  the  Confederate  States  Army  in  1863,  in  which  the  author  (pp.  104, 
105)  states  that  in  all  these  cases  the  Hunterian  operation  was  chosen  with 
the  distinct  end  in  view  of  combating  and  checking,  if  possible,  the  de- 
structive progress,  and,  in  some,  the  septic  tendency  of  the  inflammation. 
Dr.  D.  F.  Wright,  of  Tennessee,  reported  hi  1866  s  five  other  cases,  under 

1  Surgery  of  the  Arteries,  London,  1875,  p.  163. 

-  Henry  F.  Campbell :  The  Hunterian  Ligation  of  Arteries  to  Relieve  and  Prevent 
Destructive  Inflammation.  Southern  Journal  of  the  Medical  Sciences,  August,  1866. 

3  Therapeutic  Effects  of  the  Ligation  of  Arteries.  Richmond  Medical  Journal, 
April,  1866. 


TREATMENT    OF    GANGRENE.  227 

his  observation,  in  which  the  Hunterian  ligation  of  the  main  arterial  trunk 
of  a  limb  had  been  done  for  the  arrest  of  secondary  haemorrhage,  and  in 
all  of  which,  immediately  from  the  date  of  ligation,  "  large  tumefaction  had 
been  superseded  by  recovery  of  the  original  contour,  fetid  ichorous  dis- 
charge by  laudable  suppuration,  and  phagedenic  gangrene  by  vigorous 
granulations." 

Mr.  Maunder,  of  London,  in  his  work  on  "  The  Surgery  of  the  Arte- 
ries," reports  six  cases  of  ligature  of  arteries  for  the  control  of  traumatic 
inflammation,  and  after  discussing  the  various  aspects  of  the  practice,  sum- 
marizes his  experience,  thus  : 

"  That  ligature  of  the  superficial  femoral  artery  has  arrested  acute  in- 
flammation consequent  on  wound  of  the  knee-joint. 

"  That  ligature  of  a  main  artery  will  quickly  diminish  profuse  suppura- 
tion and  prevent  death  by  exhaustion. 

"That,  while  it  arrests  profuse  suppuration,  it  will,  by  allowing  the 
patient  to  gain  strength,  afford  an  opportunity  for  amputation  at  a  future 
time. 

"  That  gangrene  and  secondary  haemorrhage,  as  the  result  of  ligature, 
should  not  be  anticipated  in  the  healthy  subject" 

R£SUM£. — The  various  resources  which  have  been  mentioned  for  antag- 
onizing and  mitigating  traumatic  inflammation  are  sanctioned  by  the  prac- 
tice of  the  past  and  by  the  authority  of  surgical  teachers ;  but  the  more 
accurate  knowledge  of  the  present  with  reference  to  the  essential  causes  of 
inflammatory  disturbances  of  wounds  must  relegate  them  to  a  less  impor- 
tant place,  while  the  greatest  importance  must  attach  to  those  measures 
which  may  rid  a  wound  of  the  agents  and  subjects  of  sepsis.  Free  inci- 
sions for  the  relief  of  tension  and  the  escape  of  debris,  adequate  drainage, 
cleanliness  in  the  aseptic  sense  of  the  term,  with  proper  protection  and  per- 
fect rest,  afford  the  surest  and  speediest  means  of  overcoming  inflamma- 
tion, since  they  remove  its  causes,  carry  away  its  products,  and  favor  in 
the  highest  degree  the  natural  nutritive  processes  of  the  part,  by  means  of 
which  recovery  from  damage  already  sustained  is  to  be  secured,  and  repair 
of  the  original  injury  is  to  be  accomplished. 

GANGRENE. 

The  appearance  of  spreading  gangrene  in  a  wound  calls  for  immediate 
energetic  antiseptic  treatment  to  destroy  the  micro-organisms,  the  caustic 
products  of  whose  vital  activity,  as  they  successively  invade  new  tissues, 


228  THE    TREATMENT    OF    WOUNDS. 

produces  the  gangrenous  phenomena.  All  necrosed  tissue  should  be 
removed  at  once  with  knife  and  scissors,  and  the  living  tissues  exposed 
should  be  freely  and  thoroughly  cauterized  by  the  eight  per  cent,  chloride 
of  zinc  solution,  which  should  be  injected  into  every  recess  and  irregu- 
larity of  the  wound.  The  swollen  and  infiltrated  tissues  leading  from  the 
gangrenous  focus,  particularly  the  intermuscular  interstices  and  the  sub- 
cutaneous connective  tissue,  should  be  opened  by  numerous  small  incisions 
through  the  integument  to  permit  the  escape  of  secretions  and  of  debris 
and  to  enable  the  disinfecting  fluid  to  be  introduced  into  as  many  places 
as  possible.  Longer  incisions  and  counter-incisions  may  be  made  as 
shall  be  required  for  the  relief  of  tension  and  for  the  freest  imaginable 
drainage.  When  gangrene  has  attacked  a  wound,  the  wound  must  be  kept 
exposed,  so  that  its  condition  may  be  under  continuous  observation  while 
the  means  of  powerful  and  permanent  disinfection  are  being  employed. 
An  open  method  of  treatment  with  continuous  antiseptic  irrigation  offers  a 
most  effective  means  which  will  overcome  the  most  serious  cases  of  sepsis 
when  all  other  precautions  have  been  found  insufficient.  The  adjacent  in- 
tegument should  be  frequently  anointed  with  vaseline  to  protect  it  from 
the  macerating  influence  of  the  irrigation. 

As  an  irrigating  fluid,  a  dilute  solution  of  carbolic  acid  (one  per  cent.) 
is  adequate.  As  a  substitute  for  carbolic  acid  in  making  permanent  irri- 
gation, Bruns,1  of  Tubingen,  advocates  the  use  of  weak  solutions  of  acetate 
of  alumina  (one-half  of  one  per  cent).  This  has  sufficient  antiseptic 
strength,  and  does  not  produce  eczema  or  intoxication.  The  antiseptic  ir- 
rigation should  be  continued  until  the  wound  is  rendered  perfectly  aseptic, 
lodoform  dressings  then  will  be  particularly  applicable  as  protective  and 
absorbent  dressings. 

The  general  strength  of  the  patient  must  be  kept  up  by  the  liberal  use 
of  alcoholic  stimulants,  by  nutritious  food,  by  tonics,  and  by  anodynes. 

ERYSIPELAS. 

When  the  repair  of  a  wound  becomes  disturbed  by  erysipelas,  the  pa- 
tient should  at  once  be  isolated.  A  surgeon  or  attendant  should  not  pass 
from  the  care  of  an  erysipelatous  case  to  that  of  a  healthy  wound  until 
after  the  most  thorough  antiseptic  precautions  for  securing  cleanliness 

1  Die  permanente  Irrigation  mit  emgsaurer  Thonerde.  Berlin.  kliniscTie  Wochen- 
schrift,  1878,  No.  30. 


TREATMENT   OF   ERYSIPELAS.  229 

have  been  observed.  The  appearance  of  erysipelas  is  always  due  to  some 
defect  or  neglect  in  the  antiseptic  precautions.  Greater  care  is  required 
to  prevent  the  occurrence  of  erysipelas  than  of  suppurative  and  putrefac- 
tive reactions  in  general,  but  adequate  means  to  keep  wounds  aseptic  have 
been  proven  to  be  efficient  barriers  against  its  development  The  remark- 
able experience  of  Nussbaum  that,  although  previous  to  the  introduction 
of  aseptic  methods  of  treating  wounds  into  the  General  Hospital  of  Mu- 
nich, almost  every  wound  was  attacked  with  erysipelas,  and  after  its  intro- 
duction no  instance  of  erysipelas  occurred,  has  already  been  referred  to  in 
a  previous  chapter  (Chapter  HL).  Similar,  though  less  absolutely  perfect 
results,  have  attended  the  attempts  at  aseptic  methods  of  other  surgeons. 
The  first  thing  to  be  recognized,  therefore,  upon  the  appearance  of  ery- 
sipelas in  a  wound  is  that  it  is  of  specific  septic  origin,  and  that  it  most 
especially  calls  for  those  methods  of  treatment  which  are  adapted  to  sep- 
tic wounds.  It  is  no  longer  correct  to  say  that  the  pathology  of  erysipelas 
is  still  involved  in  obscurity ;  the  researches  of  Fehleisen,  referred  to  in 
Chapter  HL,  page  44,  have  definitely  demonstrated,  what  had  already  been 
inferred  by  many  observers,  that  erysipelas  is  due  to  the  infection  of  a 
wound  by  a  specific  micro-organism,  a  micrococcus.  Based  upon  this,  it 
is  possible  to  construct  a  rational  and  efficient  therapeutics  of  the  disease. 
Treatment  may  be  directed  for  the  purpose  of  either : 

1.  Destroying  or  rendering  inert  the  specific  micrococcus.     Antiseptics. 

2.  Increasing  the  resisting  powers  of  the  invaded  tissues.     Tonics  and 
stimulants. 

3.  Alleviating    the    local    inflammation   and   removing   its   products. 
Antiphlogistics. 

ANTISEPTICS. — The  power  of  antiseptic  substances  is  more  readily  exer- 
cised as  a  preventive  means  than  as  a  curative  resource.  The  infiltration 
of  the  tissues  with  the  micro-organisms  tends  to  render  them  inaccessible 
to  antiseptic  applications,  unless  these  be  of  sufficient  strength  to  destroy 
the  tissues  as  well  The  germs,  according  to  Fehleisen,  spread  along  the 
lymphatics  only,  but  their  dissemination  takes  place  not  only  along  the 
course  of  the  lymph  stream,  but  in  all  directions,  without  reference  to  the 
direction  of  the  lymph  current  Their  destruction,  when  isolated,  by  anti- 
septic agents,  was  experimentally  demonstrated  by  Fehleisen  with  carbolic 
acid  and  corrosive  sublimate.  The  isolated  micrococci,  exposed  to  the 
action  of  a  three  per  cent  solution  of  carbolic  acid  for  twenty  seconds, 
remained  active  and  potent ;  when  exposed  for  thirty  seconds,  their  devel- 


230  THE   TREATMENT   OF   WOUNDS. 

opment  was  imperfect  and  retarded  ;  when  exposed  for  forty-five  seconds, 
they  were  destroyed  altogether.  A  one  per  cent,  solution  of  corrosive 
sublimate  destroyed  them  much  more  quickly,  an  exposure  of  ten  to  fifteen 
seconds  being  sufficient  to  prevent  their  development.  Fischer, '  of  Strass- 
burg,  claims  for  naphthalin  that  it  has  a  specific  power  to  antagonize  the 
micro-organisms  of  erysipelas. 

Subcutaneous  Injections. — Hueter,"  of  Greifswald,  in  1875  recommended 
the  early  subcutaneous  injections  of  dilute  watery  solutions  of  carbolic  acid. 
Hypodermic  injections  of  salicylic  acid  have  also  been  used  with  success. 

The  use  of  subcutaneous  injections  of  antiseptic  solutions  to  abort 
attacks  of  erysipelas  has  been  found  to  be  most  certainly  successful  when 
employed  at  the  onset  of  an  attack  ;  later,  when  the  infiltration  of  the 
pathogenic  organisms  and  the  inflammatory  reaction  has  attained  a  greater 
extent,  it  becomes  less  probable  that  the  antidote  can  be  injected  so  as  to 
come  in  contact  with  the  noxious  particles  in  sufficient  quantity  and  to  the 
necessary  extent  Differences  in  the  stage  of  the  disease  at  which  these 
injections  are  practised,  and  in  the  manner  in  which  the  injection  is  per- 
formed, will  explain  much  of  the  differences  in  the  results  obtained  by 
different  surgeons. 

The  antiseptic  to  be  used  must  be  one  that  is  not  too  irritating,  that 
is  diffusible,  and  that  will  not  coagulate  the  tissues  among  which  it  is  in- 
troduced. Carbolic  acid,  in  dilute  watery  solution,  answers  these  indica- 
tions better  than  any  other  agent  of  equal  antiseptic  power.  Carbolic 
acid  was  the  antiseptic  used  by  Hueter.  The  method  of  its  use  finally 
settled  upon  by  him  *  was  to  inject  three  to  five  hypodermic  syringefuls 
of  a  three  per  cent  watery  solution  of  the  acid,  at  numerous  points,  into 
the  healthy  subcutaneous  tissues  along  the  borders  of  the  erysipelatous 
patch.  These  injections  demand  repetition  once  or  twice,  according  to  the 
intensity  of  the  inflammation  and  its  tendency  to  extend.  Even  three  or 
four  repetitions  may  be  needed  before  the  erysipelas  will  cease  to  advance. 
In  but  few  cases  will  this  method  of  treatment  fail  to  greatly  circumscribe 
the  disease. 

E.  Boeckel,4  of  Strassburg,  after  testing  the  method  in  a  series  of  cases, 

1  Centralblatl  fur  Chirurgie,  Nov.  29,  1882.  Beilage,  p.  3,  Congress  of  German 
Surgeons,  1882. 

*  Deutsche  Zeitschrift  f&r  Chirurgie,  1875,  4  Bd.,  Heft  5  and  6. 

3  Schiiller.    Jahresbericht.    Deutsche  Zeitschrift  fur  Chirurgie,  1878. 

4  Gazette  Medicale  de  Strasbourg,  1875,  No.  5. 


TREATMENT    OF    ERYSIPELAS.  231 

concludes  that,  while  injections  of  carbolic  acid  are  not  a  panacea,  yet  they 
constitute  the  most  certain  remedy  which  we  possess.  By  injecting,  morn- 
ing and  evening,  from  five  to  six  hypodermic  syringefuls  of  a  one  and  a 
half  per  cent,  carbolic  solution,  one-fifth  of  an  inch  from  the  inflamed 
border,  along  the  entire  circumference  of  the  erysipelatous  patch,  he  was 
frequently  successful  in  arresting  a  very  severe  erysipelas  within  twenty- 
four  hours. 

Tillmans,1  of  Leipzig,  is  of  opinion  that  subcutaneous  injections  of  car- 
bolic acid  have  their  greatest  usefulness  in  preventing  or  mitigating  a 
threatened  outbreak  of  erysipelas,  and  that  for  this  end  they  should  be 
energetically  used  at  the  beginning  of  an  attack.  He  quotes  Kiister,  of 
Berlin,  as  also  of  the  opinion  that,  at  the  onset  of  an  attack,  the  measure  is 
of  great  value,  but  that  later  it  is  wholly  or  nearly  worthless. 

To  some  surgeons  it  has  happened  that  abscesses  have  frequently 
formed  at  the  sites  of  the  injections.  This,  however,  can  be  easily  avoided 
by  care  that  only  a  clean  syringe  be  used  in  making  the  injections,  and  by 
directing  the  point  of  the  needle  in  various  directions,  so  that  the  fluid 
injected  is  diffused  over  a  larger  extent  of  tissue. 

Superficial  Applications. — The  application  of  antiseptic  substances  to  the 
surface  of  the  skin  in  many  cases  is  of  benefit,  but  the  results  are  compar- 
atively uncertain  and  weak.  Tincture  of  iodine,  tincture  of  the  chloride 
of  iron,  tar,  strong  solutions  of  nitrate  of  silver,  of  sulphate  of  iron,  of  sali- 
cylate  of  sodium,  of  carbolic  acid,  and  other  agents,  have  been  used  by 
various  surgeons,  and  in  turn  have  been  esteemed  as  of  value  and  as 
inefficient 

Naphthalin,  made  into  an  ointment  with  vaseline,  or  other  appropriate 
excipient,  in  the  strength  of  from  ten  to  twenty  per  cent.,  and  thoroughly 
smeared  over  the  affected  surfaces,  will  cause  the  unpleasant  subjective 
symptoms  of  erysipelas  to  disappear  rapidly,  followed  by  a  more  slow  sub- 
sidence of  the  swelling  or  cedema.  Usually  its  application  beyond  the 
limits  of  the  disease  will  check  its  further  spread,  or  at  least  mitigate  it. 

TONICS  AND  STIMULANTS. — The  general  depression  and  febrile  reaction 
which  attend  attacks  of  erysipelas  are  themselves  the  results  of  septic  in- 
fection by  absorption  of  the  products  of  the  local  disease.  With  the  sub- 
sidence of  the  local  disease,  the  general  symptoms  also  disappear,  and  yet 
by  reason  of  the  general  depression  of  the  natural  resisting  power  of  the 

1  Erysipelas.     Deutsche  Chirurgie,  Lieferung  5,  1880. 


232  THE   TREATMENT    OF    WOUNDS. 

body  which  they  produce,  they  may  contribute  to  the  greater  severity  and 
the  prolongation  of  the  local  trouble.  Those  general  remedies,  therefore, 
will  be  of  value  which  shall  either  contribute  to  general  nutrition,  or  shall 
act  as  stimulants  and  roborants.  A  supporting  diet  is  of  importance.  The 
use  of  proper  means  to  keep  the  digestive  and  excretive  apparatus  in  active 
condition  must  be  resorted  to.  Tincture  of  the  chloride  of  iron,  quinine, 
and  opium  are  of  great  value  in  many  cases. 

ANTIPHLOGISTICS. — Since  the  local  inflammatory  phenomena  which  mark 
erysipelas  constitute  its  most  obvious  symptoms,  the  mitigation  of  these 
phenomena  constitute  a  very  important  part  of  the  treatment  called  for. 
The  treatment  of  the  inflammation  is  to  be  conducted  on  the  same  princi- 
ples and  by  the  same  methods  which  have  been  discussed  in  the  first  part 
of  this  chapter.  When  the  inflammation  is  limited  to  the  skin  only,  those 
applications  which  will  soothe  and  protect  it  find  use.  A  layer  of  absorb- 
ent material  kept  saturated  with  a  lotion  of  lead  and  opium  (liquor, 
plumbi  subacetatis,  §  j.  ;  tinct  opii,  §  ss.  ;  aquae  fervent,  Oj.)  is  an  ex- 
cellent application  ;  or  the  skin  may  be  dusted  with  finely  powdered 
starch,  lycopodium,  or  subcarbonate  of  bismuth,  and  covered  by  a  layer  of 
cotton  wool ;  or  it  may  be  anointed  with  oil  or  vaseline,  either  pure,  or  con- 
taining some  antiseptic,  or  sedative,  or  astringent  substance. 

When  the  deeper  structures  are  involved  in  the  inflammation — phleg- 
monous  erysipelas — all  the  resources  of  art  for  the  control  and  relief  of  in- 
flammation become  drawn  upon.  Position,  rest,  cold,  heat,  immersion, 
antiseptic  irrigation,  multiple  incisions,  drainage,  compression,  depletion, 
are  to  be  used,  each  in  accordance  with  the  indications  and  methods 
already  laid  down  for  combating  inflammation  in  general 

SEPTIC^MIA. 

Septicaemia  is  a  generic  term  that  includes  every  grade  of  general  sep- 
tic infection  produced  by  the  absorption  of  septic  wound-products,  from  a 
slight  febrile  reaction  to  the  cases  of  more  intense  blood-deterioration  with 
the  formation  of  diffused  secondary  suppurating  and  septic  foci  (Pyaemia). 

LOCAL  TREATMENT.  - — All  that  has  been  said  as  to  the  treatment  of  local 
septic  disturbances  applies  with  equal  force  to  the  treatment  of  general 
blood-infection,  for  where  further  new  supplies  from  local  septic  foci  are 
arrested,  the  return  of  the  blood  to  its  normal  state,  by  the  elimination 
and  destruction  of  the  septic  matters  already  mingled  with  the  circulating 


TREATMENT    OF   SEPTICAEMIA.  233 

fluids,  begins  at  once  to  be  manifest  Local  disinfection,  therefore,  is  the 
first  and  most  important  matter  to  be  accomplished  in  the  treatment  of 
traumatic  septicaemia. 

Secondary  abscesses,  whenever  they  are  accessible,  should  be  treated 
upon  the  same  principles  as  the  primary  suppurating  depots. 

Resection  of  joints  and  amputation  of  limbs  may  become  necessary  in 
some  cases  when  less  radical  means  fail  to  render  the  wound  aseptic. 

GENERAL  TREATMENT. — The  indications  to  be  met  by  general  treatment 
are  to  mitigate  general  symptoms,  to  favor  elimination,  to  counteract  pros- 
tration, and  to  relieve  organic  complications  as  they  arise. 


PART  II. 

SPECIAL    "WOUNDS. 


SECTION  I. 

YAKIETIES  THAT  MAY  OCCUK  IN  ANY  PART  OF 

THE  BODY. 


CHAPTER  XIII. 

SUBCUTANEOUS    WOUNDS— INCISED  WOUNDS— CONTUSED 
WOUNDS— LACERATED  WOUNDS. 

Subcutaneous  Haemorrhage — Restriction  and  Absorption  of  Effusions — Massage — Dry 
Cupping — Sorbef acients — Inflammation — Incised  Wounds — Rest —  Contused  and 
Lacerated  Wounds — Peculiarities — Secondary  Haemorrhage — Primary  Cleansing — 
Drainage — Necrosis  of  Tissue — Coaptation — Period  of  Granulation — Contused 
Punctured  Wounds — Incisions. 

SUBCUTANEOUS   WOUNDS. 

THE  perfection  of  the  protection  which  the  unbroken  skin  affords  to  a  sub- 
cutaneous wound  simplifies  very  much  the  treatment  which  is  demanded, 
while  it  at  the  same  time  diminishes  very  greatly  the  dangers  to  be  appre- 
hended of  disturbances  arising  in  the  course  of  its  healing.  As  subcxi- 
taneous  wounds  may  be  of  every  grade  of  severity,  from  a  slight  bruise  to 
ruptures  and  lacerations  of  important  organs,  and  the  disorganization  of 
extensive  masses  of  tissue,  the  amount  and  character  of  the  treatment 
which  they  must  receive  will  greatly  differ.  Mere  inspection  may  not  be 
sufficient  to  reveal  the  amount  of  damage,  the  repair  of  which  is  to  engage 
the  assistance  of  the  surgeon,  nor  may  its  full  amount  be  recognizable 
until  after  some  time,  when  its  subsequent  course  shall  have  demonstrated 
more  fully  its  extent  by  the  degree  of  functional  disturbance  which  results 
from  it 

The  most  important  indications  of  treatment  presented  by  subcutaneous 
wounds  are  the  control  of  haemorrhage,  the  restriction  and  absorption  of 
effusions,  and  the  maintenance  of  the  injured  parts  at  rest  until  their  con- 
tinuity has  been  restored  with  tissue  of  sufficient  firmness  to  again  endure 
the  functional  activity  of  the  part. 

SUBCUTANEOUS  HEMORRHAGE. — The  mutual  pressure  of  the  parts  among 
which  the  bleeding  point  lies  is  usually  sufficient  to  restrict  within  moder- 
ate limits  subcutaneous  haemorrhage.  This  is  still  further  aided  by  the 


238  THE    TREATMENT    OF    WOUNDS. 

irregularities  of  the  rents  in  the  vessels  themselves,  which  tend  to  entangle 
the  fibrine  of  the  blood,  and  to  produce  clot-plugs  that  may  seal  them  up. 
Haemorrhages  into  the  great  cavities  of  the  body,  however,  having  less  re- 
straint upon  their  flow,  tend  in  many  cases  to  speedy  death.  When  large 
arteries  are  ruptured  subcutaneously,  it  is  necessary  to  freely  expose  the 
point  of  rupture  by  incision,  and  ligate  upon  both  the  proximal  and  the 
distal  sides  of  the  rupture.  The  further  treatment  of  the  wound  is  then 
removed  from  the  category  of  subcutaneous  wounds.  The  most  frequent 
subcutaneous  hsemorrhages  are  those  which  attend  contusions  and  result 
from  rupture  of  subcutaneous  veins  and  capillaries,  the  amount  of  the 
extravasation  depending  upon  the  vascularity  of  the  part  and  the  severity 
of  the  contusion.  The  connective  and  muscular  tissue  interspaces  become 
infiltrated  with  the  effused  blood,  and  even  more  or  less  distinctly  bounded 
cavities  containing  blood  may  be  formed.  The  discolorations  produced 
from  the  wide  diffusion  of  extravasated  blood,  by  their  extent,  mark  its 
degree,  and  persist  for  a  long  time. 

Special  treatment  to  control  haemorrhage  of  this  character  is  rarely 
called  for.  "When  the  continuance  of  haemorrhage  is  evident,  compression 
by  means  of  an  evenly  applied  bandage,  with  or  without  an  intervening 
compress,  will  suffice  for  its  control  The  application  of  cold  would  also 
be  an  additional  available  resource. 

RESTKICTION  AND  ABSORPTION  OF  EFFUSIONS. — The  arrest  of  haemorrhage  is 
to  be  followed  by  the  use  of  means  to  restrict  the  amount  of  active  hyper- 
semia  within  the  limits  needed  for  repair.  Cold  lotions,  evaporating 
lotions,  or  ice-bags,  are  of  value  as  applications  to  overcome  any  tendency 
to  excessive  afflux,  but  the  most  valuable  and  powerful  resource  exists  in 
immobilization  and  methodical  compression  after  the  methods  described 
in  Chapter  XL  When  material  division  of  structure,  as  in  the  case  of 
fractures  of  bones,  or  the  rupture  of  muscles  or  tendons,  has  taken  place, 
this  immobilization,  in  a  position  that  shall  favor  the  apposition  of  the 
divided  surfaces,  must  be  continued  until  complete  and  firm  reunion  has 
been  established. 

The  absorption  of  effusions  is  likewise  promoted  in  a  remarkable  degree 
by  compression.  To  this  should  be  added,  especially  in  the  more  severe 
cases  of  contusion  and  sprain,  those  means  of  preventing  or  overcoming 
the  passive  dilatation  of  the  blood-vessels  prone  to  remain  after  the  first 
period  of  active  hyperasmia,  and  of  diffusing  the  effusion,  and  thus  pro- 
moting its  absorption,  which  are  found  in  methodically  rubbing,  kneading, 


MASSAGE SOEBEFACIENTS.  239 

percussing,  and  rolling  the  soft  parts,  with  passive  movements,  which  con- 
stitute "massage." 

Massage  may  be  used  very  early  after  an  injury,  within  the  first 
twenty-four  hours.  The  skin  over  the  affected  part  should  be  anointed 
with  oil  to  protect  it,  for  it  is  the  deeper  tissues  that  are  particularly  to  be 
affected  by  the  kneading.  The  thumbs  and  fingers  are  then  to  be  applied 
with  steady  and  firm  pressure,  their  force  being  graduated  according  to 
the  tenderness  of  the  part,  so  as  through  the  skin  to  rub,  and  knead,  and 
roll  the  deeper  tissues,  diffusing  the  exudations  present,  stimulating  the 
languid  circulation,  and  exciting  the  absorbents.  The  manipulations 
should  be  begun  beyond  the  margins  of  the  tumefied  and  painful  spots, 
which  should  be  gradually  approached.  The  soothing  effect  of  the  rub- 
bing, when  patiently  and  delicately  applied,  is  such  that  soon  pressure  and 
movement  over  the  points  of  chief  injury  are  readily  tolerated.  By  mas- 
sage a  more  speedy  relief  from  pain  and  swelling,  and  an  earlier  restora- 
tion of  the  function  of  the  part  can  be  secured  in  many  cases  than  by  any 
other  method.  It  is  particularly  of  value  in  the  treatment  of  contusions, 
distortions  and  sprains  of  joints,  and  their  sequelae.1 

Dry  Cupping. — The-  appli cation  of  dry  cups  to  the  surface  of  the  skin 
over  the  area  of  injury  will  powerfully  assist  in  diffusing  the  effusions  con- 
sequent upon  contusions  of  the  deeper  parts,  and  will  contribute  to  the 
comfort  and  the  more  speedy  restoration  of  the  function  of  the  injured 
part. 

Sorbefacients. — The  use  of  various  lotions  for  their  presumed  power  in 
stimulating  the  absorption  of  effusions,  though  a  popular  and  common 
resort,  cannot,  as  a  rule,  be  commended  as  of  value.  Their  power  to  allay 
the  violence  of  the  primary  afflux  by  their  cooling  or  sedative  properties 
is  more  marked.  According  to  Gross,2  the  most  trustworthy  sorbefacient 
is  a  strong  solution  of  chloride  of  ammonium  with  the  addition  of  a  small 
quantity  of  vinegar,  applied  upon  folded  flannel,  covered  with  oiled  silk, 
and  renewed  six  or  eight  times  in  the  twenty-four  hours. 

Douching  a  part  with  hot  water,  as  hot  as  can  be  borne  without  suffer- 
ing, continued  for  from  twenty  to  thirty  minutes,  acts  energetically  in 
producing  contraction  of  the  dilated  vessels  and  in  restoring  tone  to  the 
circulation  and  nutrition  of  an  injured  part,  and  in  promoting  absorption 

1  Douglas  Graham,  M.D.  :  The  Treatment  of  Sprains  by  Massage.  The  Medical 
Record,  August  11,  1877,  p.  504. 

*  System  of  Surgery,  1882,  vol.  i.,  p.  354. 


240  THE    TREATMENT    OF    WOUNDS. 

of  effusions.  As  an  immediate  application  after  a  contusion  or  sprain,  hot 
water,  either  in  the  form  of  a  douche,  bath,  or  by  compresses,  is  preferable 
to  cold  applications  by  reason  of  the  diminished  tendency  to  passive  con- 
gestion which  follows  its  use.  When  the  effused  blood  is  collected  in 
depots,  if  its  presence  is  a  cause  of  discomfort  or  serious  functional  dis- 
turbance, it  may  be  removed  by  aspiration,  or  through  "incision  made  in 
the  overlying  integument,  provided  strict  surgical  cleanliness  be  used  to 
prevent  the  agents  of  putrefaction  from  gaining  access  to  the  exposed 
cavity. 

INFLAMMATION,  complicating  subcutaneous  wounds,  is  to  be  treated  in 
accordance  with  the  general  principles  laid  down  elsewhere.  When  sup- 
purative  and  putrefactive  disturbances  intervene,  free  incisions  to  evacuate 
septic  matters  must  be  made,  and  the  general  treatment  already  insisted 
upon  for  septic  wounds  followed. 

INCISED   WOUNDS. 

The  treatment  of  simple  cut  or  incised  wounds  presents  fewer  elements 
of  difficulty  than  do  those  forms  of  wounds  which  are  accompanied  by 
more  extended  damage  to  the  adjacent  tissues.  In  the  arrest  of  haemor- 
rhage, which  in  general  will  be  accomplished  with  but  little  difficulty,  the 
means  of  haemostasis  should  be  adopted  which  will  not  be  likely  to  intro- 
duce sources  of  disturbance  in  the  after-course  of  the  healing.  Bleeding 
from  all  but  vessels  of  considerable  size  will  be  arrested  by  exposure  to 
the  air,  or  by  the  application  of  hot  water,  aided  by  compression.  The 
mutual  compression  of  the  wound-surfaces  against  each  other,  after  they 
have  been  brought  into  apposition,  serves  to  restrain  any  tendency  to 
farther  haemorrhage.  When  ligatures  are  required,  only  those  that  are 
aseptic  should  be  employed,  the  preference  being  given  to  those  of  animal 
material  that  can  be  spontaneously  absorbed. 

The  haemorrhage  from  incised  wounds  in  which  large  blood-vessels  are 
opened  seldom  ceases  spontaneously ;  they  constitute  the  most  dangerous 
class  of  wounds,  and  quickly  terminate  fatally  from  loss  of  blood.  The 
most  energetic  and  instant  resort  to  measures  for  the  arrest  of  haemorrhage 
is  called  for  in  these  cases.  When  a  vessel  is  but  partially  divided,  it  is 
more  difficult  to  stay  the  bleeding  from  it  than  if  the  division  is  complete. 
In  such  cases  the  first  thing  to  be  done  is  to  complete  the  division  of  the 
vessel 


INCISED    WOUNDS.  241 

The  cleansing  of  the  wound  is  less  difficult  to  accomplish ;  its  surfaces 
are  lined  with  a  minimum  amount  of  devitalized  tissue,  for  the  absorption 
and  removal  of  which,  without  disturbance  arising  from  its  decomposition, 
the  ordinary  reparative  energy  of  the  adjacent  tissues  is  usually  quite 
adequate  when  coaptation  is  effected,  even  without  minute  precautions  to 
exclude  from  contact  with  it,  while  exposed,  any  pathogenic  germs.  The 
drainage  of  incised  wounds,  when  proper  care  is  exercised  to  maintain 
their  deeper  parts  in  apposition,  is  very  simple.  In  the  more  extensive 
wounds,  it  needs  the  use  of  capillary  drains  for  the  first  twenty-four  hours 
only,  during  the  period  of  the  most  energetic  afflux  consequent  upon  the 
wound  ;  in  a  large  proportion  of  cases,  where  compression  and  immobiliza- 
tion of  the  wounded  part  can  be  effected,  no  provision  for  drainage  is 
required. 

The  apposition  of  the  wound-surfaces  should  be  attended  to  with  the 
utmost  care  and  minuteness,  so  that  by  the  use  of  sutures,  compresses, 
bandages,  and  position,  the  coaptation  of  every  part  should  be  perfect,  and 
no  spaces  be  left  for  the  collection  of  secretions.  The  reunion  of  parts 
which  have  been  almost  entirely  separated  from  the  body  may  not  infre- 
quently be  secured  by  minute  attention  to  their  coaptation.  Albanese,  of 
Palermo,  Italy,  reported '  at  the  session  of  the  International  Medical  Con- 
gress at  London  in  1881,  a  remarkable  instance  of  such  reunion.  In  this 
case  the  wrist  had  been  almost  completely  cut  through,  with  the  bones  and 
the  flexor  and  extensor  tendons,  so  that  the  hand  hung,  held  to  the  fore- 
arm only  by  a  slip  of  skin  in  the  dorsal  region  about  one  and  a  half 
inch  wide.  The  radial  and  ulnar  arteries  were  ligated,  the  severed  sur- 
faces were  brought  into  contact  with  pin  sutures,  and  immobilization  was 
effected  by  a  plastic  splint.  Slight  gangrene  appeared  in  the  thenar 
region.  The  temperature  and  sensibility  of  the  hand  and  fingers  were 
sensibly  lowered  for  a  long  time.  The  vitality  of  the  hand  as  a  whole  was 
preserved,  and  its  reunion  to  the  forearm  accomplished  with  ankylosis  at 
the  carpal  articulation,  and  mobility  at  the  radio-carpal  articulation.  The 
fingers  were  at  first  immovable,  but  gradually  acquired  some  movement, 
until  finally  they  became  quite  useful 

The  protective  dressings  required  by  incised  wounds,  the  coaptation  of 
whose  surfaces  is  possible,  are  very  simple.  Exposure  of  the  line  of  suture 
to  the  air,  so  that  the  desiccation  of  the  slight  amount  of  secretion  that 

1  Transactions  International  Medical  Congress,  1881,  ii. ,  p.  438. 
16 


242  THE   TREATMENT    OF    WOUNDS. 

gathers  there  may  form  a  protective  crust  gives  excellent  results  when  the 
conditions  of  the  wound  are  such  as  to  make  it  practicable.  A  light,  dry, 
clean  absorbent  dressing  of  some  kind  is  all  that  is  required  at  any  time. 

The  provisions  of  "  rest,"  in  the  case  of  incised  wounds,  may  and  should 
be  made  absolute.  When  proper  care  has  been  taken  in  the  other  details 
of  the  treatment  of  an  incised  wound,  that  infraction  of  its  rest  involved  in 
the  removal  and  readjustment  of  its  dressings  may  be  long  deferred  ;  the 
surgeon  can  consider  his  dressing  as  having  been  perfect  only  when,  after 
the  expiration  of  a  week  or  ten  days,  during  which  no  local  discomfort  or 
constitutional  disturbance  having  been  noticeable,  removal  of  the  dressings 
and  inspection  of  wound  shows  it  to  be  healed  throughout. 

The  development  of  inflammatory  disturbance  or  of  septic  conditions, 
in  the  course  of  the  repair  of  an  incised  wound,  unless  the  inflammation 
and  septicity  were  already  present  before  it  came  under  the  care  of  the 
surgeon,  is  a  reflection  upon  the  character  of  the  treatment,  and  calls  for 
special  explanation  upon  the  part  of  the  surgeon  to  exonerate  himself  from 
blame  therefor. 


CONTUSED  AND  LACERATED  WOUNDS. 

Since  the  extent  of  the  tissue  damage  which  has  been  sustained  by  the 
parts  that  are  the  subjects  of  contused  or  lacerated  wounds  is  not  to  be 
determined  by  the  amount  of  the  apparent  injury  visible  at  the  first  exam- 
ination, its  treatment  has  to  be  conducted  with  a  degree  of  care  and  watch- 
fulness, and  provision  for  probable  causes  of  disturbance,  that  do  not 
embarrass  the  surgeon  in  the  management  of  incised  wounds.  The  sur- 
face breach  is  generally  much  less  than  the  breach  sustained  by  the  deeper 
tissues,  and  the  wound  is  complicated  by  the  presence  of  much  tissue  that 
has  been  damaged  by  the  traumatism,  the  life  of  which  is  to  be  preserved 
only  by  great  care  in  fostering  its  nutrition,  and  preventing  the  access  of 
inflammatory  disturbancea 

The  primary  haemorrhage  from  these  wounds  is  less  apt  to  imperatively 
demand  the  attention  of  the  surgeon  for  its  control  than  in  the  case  of 
incised  wounds,  on  account  of  the  favorable  condition  of  the  parts  for  its 
spontaneous  arrest  produced  by  the  nature  of  the  traumatism,  even  large 
vessels  being  frequently  spontaneously  plugged  by  the  retraction  and  in- 
turning  of  their  separated  inner  tunic,  and  by  the  interlacing  of  the  irreg- 
ular ends  of  the  external  tunic  and  the  surrounding  connective  tissue. 


CONTUSED    AND    LACERATED    WOUNDS.  243 

On  the  other  hand,  secondary  haemorrhages  occur  with  more  frequency 
on  account  of  the  sloughing  of  parts  of  the  wall  of  a  vessel,  either  because 
its  vitality  had  been  so  far  destroyed  by  the  original  force,  which  had  yet 
fallen  short  of  opening  it,  that  it  failed  to  become  restored,  and  so  ulti- 
mately necrosed,  or  because  the  vessel  became  involved  in  destructive 
inflammatory  processes  complicating  the  after-course  of  the  wound. 

The  period  during  which  the  separation  of  sloughs  caused  by  the  orig- 
inal injury  is  taking  place,  is  thus  a  period  of  danger.  This  is  usually 
between  the  sixth  and  twelfth  days  after  the  infliction  of  the  wound. 
During  this  time,  accordingly,  special  watchfulness  against  the  occurrence 
of  haemorrhage  is  to  be  exercised. 

The  period  of  reaction  from  shock  is  also  particularly  liable  to  be  com- 
plicated by  haemorrhage  in  the  case  of  contused  and  lacerated  wounds, 
since,  though  the  blood-current,  while  weak  from  the  depressed  action  of 
the  heart,  often  finds  the  natural  obstructions  left  behind  by  the  laceration 
of  the  tissues  sufficient  to  arrest  it,  yet  when  it  is  again  driven  with  more 
energy  by  a  restored  heart,  its  force  may  be  sufficient  to  sweep  away  these 
comparatively  weak  obstructions,  and  to  determine  copious  haemorrhage. 

The  period  of  reaction  is  therefore  to  be  watched  with  especial  care  to 
guard  against  possible  haemorrhage  ;  and  in  the  first  dressing  of  a  wound 
involving  vessels  which  may  possibly  bleed,  it  is  the  part  of  wisdom  to 
apply  preventive  ligatures  to  them,  though  they  may  not  be  bleeding  at 
the  time,  providing  this  does  not  involve  undue  disturbance  of  the  wound 
hi  other  respects.  Aseptic  ligatures  should  be  used,  and  care  should  be 
taken  to  apply  the  ligature  to  a  sound  portion  of  the  vessel 

Nevertheless,  should  a  surgeon  think  it  best  to  defer  interference,  as 
long  as  no  bleeding  takes  place,  it  will  be  found  that  in  many  cases  no 
interference  will  be  necessary;  but  such  a  course  will  exact  increased 
watchfulness  until  the  repair  of  the  wound  has  sufficiently  far  advanced  to 
demonstrate  the  permanency  of  the  spontaneous  haemostasia  When,  how- 
ever, secondary  haemorrhage  has  once  occurred,  then  the  application  of  a 
ligature  is  imperative,  even  though  the  bleeding  may  have  again  spontane- 
ously ceased  as  the  heart's  action  has  weakened,  for  so  soon  as  the  reaction 
again  comes  on,  and  the  heart  beats  strongly  once  more,  the  haemorrhage 
will  surely  recur. 

The  primary  cleansing  of  the  wound  should  be  conducted  with  great 
care,  the  more  since  the  recesses  and  irregularities,  which  its  surfaces  are 
likely  to  present,  favor  the  lodgement  of  irritating  matters,  and  because  in 


244  THE   TBEATMEOT    OF    WOUNDS. 

many  instances  foreign  matter  is  ground  into  the  exposed  surfaces  at  the 
moment  of  the  injury.  All  detached  particles  of  bone  and  soft  tissue 
should  be  carefully  removed,  and  tissues  into  which  foreign  matter  has 
been  so  ground  that  the  complete  removal  of  this  dirt  is  impossible  should 
be  trimmed  with  scissors  or  knife.  Bruised  portions  of  tissue  that  are  still 
attached  should  be  carefully  cleansed  and  replaced,  and  preserved  from 
further  traumatism,  since  much  that  appears  to  be  hopelessly  destroyed 
may  yet  be  saved  in  many  cases  by  care  in  fostering  its  nutrition. 

Thorough  irrigation  of  a  contused  and  lacerated  wound  with  an  anti- 
septic lotion,  until  no  element  of  sepsis  be  left  within  it,  is  imperative,  for 
all  the  conditions  of  such  wounds  are  such  as  to  create  and  present  to  a 
large  degree  the  material  favorable  for  the  rank  development  of  septic 
organisms.  The  natural  resisting  power  of  the  tissues,  which  enables  the 
surfaces  exposed  in  ordinary  incised  wounds  to  resist  the  development  of 
sepsis,  and  to  preserve  the  minute  devitalized  fragments  of  tissue  that  are 
present  from  undergoing  putrefaction,  is  no  longer  to  be  relied  upon  in  the 
class  of  wounds  under  consideration  ;  in  these  the  bruised  wound-surfaces 
have  to  struggle  to  retain  their  own  vitality,  and  larger  masses  of  devital- 
ized tissue,  and  more  copious  effusions  of  putrefiable  secretions  have  to  be 
disposed  of. 

The  consecutive  cleansing  of  the  wound,  to  admit  of  the  free  escape  of 
wound  de'bris  of  every  kind  during  the  period  of  repair,  will  require  the 
fullest  provision  for  drainage  from  all  its  recesses.  All  the  methods  of 
securing  this,  which  have  been  discussed  in  the  earlier  part  of  this  work 
(Chapter  "ViLL ),  may  find  their  application  in  the  treatment  of  these  wounds, 
and  must  be  applied  according  to  the  judgment  of  the  surgeon,  so  as  to 
secure  the  immediate  and  full  removal  from  the  cavity  of  the  wound  of  all 
putrefiable  material  as  fast  as  formed. 

Efforts  at  accomplishing  apposition  of  the  wound-surfaces  must  be  sub- 
ordinated to  the  needs  of  drainage  and  the  provision  for  the  unhindered 
separation  of  necrotic  tissue.  In  cases  of  severe  contusion  a  degree  of 
uncertainty  will  always  exist  as  to  the  ability  to  regain  vitality  which  the 
injured  tissues  may  exhibit,  and  a  certain  amount  of  necrosis  is  to  be 
expected  and  provided  for.  This  necrosis  will  be  reduced  to  a  minimum 
in  proportion  as  the  provisions  for  making  and  keeping  the  wound  aseptic 
are  thorough  and  successful  When  adequate  antiseptic  measures  are 
practicable,  greater  efforts  at  securing  coaptation  of  the  wound-surfaces 
should  be  made,  since  they  will  be  more  likely  to  be  rewarded  with  a  cer- 


PUNCTURED    WOUNDS.  245 

tain  degree  of  primary  union  than  when  antiseptic  precautions  are  neg- 
lected. Special  care  should  be  observed  to  avoid  all  tension  of  the 
wounded  tissues  in  endeavoring  to  approximate  them.  With  this  precau- 
tion, and  those  required  for  drainage,  coaptation  may  be  attempted  by  any 
of  the  means  which  are  at  the  disposition  of  the  surgeon  for  that  purpose. 

In  a  large  proportion  of  contused  and  lacerated  wounds  there  will  be 
such  an  amount  of  destruction  of  tissue  that  any  attempt  at  closing  it  to 
secure  primary  union  will  be  manifestly  contra-indicated.  In  such  cases 
the  efforts  of  the  surgeon  are  chiefly  directed  toward  protecting  the  wound 
from  sources  of  disturbance  during  the  time  that  the  separation  of  the  de- 
vitalized tissue  and  the  repair  of  the  breach  by  granulation  is  being  effected. 

These  are  the  cases  in  which  local  septic  inflammations,  gangrene,  ery- 
sipelas, and  general  septic  infection  are  most  prone  to  occur.  For  the  pre- 
vention of  these  accidents  the  precautions  of  "  antisepsis  "  and  of  "  rest " 
should  be  rigorously  observed. 

CONTUSED  PUNCTUBED  WOUNDS,  such  as  those  formed  by  the  thrusting 
into  the  tissues  of  a  splinter  of  wood,  a  nail,  a  bayonet,  or  any  other  sub- 
stance which  is  capable  of  making  a  deep  and  narrow  wound-track,  are 
likely  to  present  difficulties  in  treatment  by  reason  of  the  trouble  that  they 
may  give  in  securing  their  disinfection  and  drainage.  The  first  thing  to 
be  attended  to,  after  the  removal  of  the  puncturing  substance  and  the 
stanching  of  haemorrhage,  if  there  be  any,  is  the  disinfection  and  cleans- 
ing of  those  parts  of  the  wound  that  are  accessible,  and  then  placing  the 
part  at  rest.  If  there  has  been  no  septic  material  introduced  into  the 
deeper  parts  of  the  wound  at  the  time  the  puncture  was  made,  and  ade- 
quate protection  be  afforded  it  thereafter,  speedy  repair  without  disturbance 
may  be  looked  for.  When,  however,  from  any  cause,  inflammation  of  the 
deeper  portions  of  the  wound  develops,  in  proportion  as  it  is  deep  and 
narrow  will  the  inflammatory  effusions  be  pent  up,  and  their  putrefaction, 
with  attendant  local  irritation  and  general  septic  infection,  be  likely  to 
occur.  They  are  septic  wounds  and  require  the  immediate  and  energetic 
application  of  the  means  of  treatment  described  as  required  by  such 
wounds  (Chapter  VEIL,  page  157). 

The  value  of  free  and  early  incisions  for  the  relief  of  pent-up  effusions 
cannot  be  overestimated  in  such  cases.  The  following  strong  putting  of  the 
value  and  necessity  of  this  measure  in  such  cases  is  by  Bryant,  of  London.  * 

1  On  Wounds.     International  Encyclopaedia  of  Surgery,  ii. ,  40. 


246  THE   TREATMENT    OP    WOUNDS. 

"  In  the  treatment  of  all  punctured  wounds,  the  surgeon  has  only  to 
remember  that,  as  their  danger  consists  in  the  difficulty  of  providing  effi- 
cient drainage,  so  their  treatment  turns  upon  this  deficiency  being  reme- 
died ;  and  the  surgeon  who,  on  the  first  appearance  of  local  or  general 
symptoms  indicative  of  the  presence  of  retained  fluids,  makes  an  outlet  by 
one  or  other  of  the  means  which  have  been  suggested — even  when  the  out- 
let is  only  for  the  escape  of  pent-up  serum — will  be  more  successful  than 
another  who,  from  timidity  or  other  cause,  leaves  the  case  to  run  its 
course,  till  a  large  inflammatory  abscess  has  formed  from  the  irritation 
caused  by  the  fluids  which  should  have  been  evacuated.  In  all  punctured 
wounds,  which  do  not  heal  quickly  by  primary  union,  and  in  which  secon- 
dary inflammation  occurs,  with  its  necessary  effusion,  it  is  the  surgeon's 
duty  to  find  an  outlet  for  the  fluids  of  the  part  as  soon  as  the  fact  of  their 
retention  is  clear.  The  artificial  formation  of  a  free  vent  for  these  fluids 
will  be  followed  by  relief,  both  locally  and  generally,  and  will  almost 
always  save  tissue  ;  whilst  delay  in  adopting  this  practice  is  not  only  locally 
deleterious,  but  may  even  prove  dangerous  to  life.  When  thecse  of  ten- 
dons, fascia!  and  fibrous  coverings,  as  of  bones,  are  involved,  the  necessity 
of  adopting  this  practice  is  more  important,  if  possible,  than  when  the 
softer  tissues  are  implicated  ;  and  an  incision  into  the  deep  parts  for  the 
evacuation  of  even  simple  serum,  by  relieving  tension,  will  often  prevent 
the  extension  of  the  inflammation,  and  prevent  destruction  of  tissue." 


CHAPTER  XIY. 

GUNSHOT  WOUNDS. 

• 

Peculiarities  of  Gunshot  Wounds  —  Haemorrhage  —  Wound-cleanliness — Immediate 
Antiseptic  Occlusion — No  Immediate  Exploration— Classification — Statistics  of 
Reyher — Non-occlusive  Treatment — Enlargement,  Cleansing,  and  Disinfection — 
Probes  and  Probing — Removal  of  Bullets— Immobilization. 

GUNSHOT  wounds  are  contused  and  punctured  wounds,  but  have  a  special 
character  by  reason  of  the  length  to  which  their  track  may  attain,  the  ex- 
tensive concealed  injuries  they  are  likely  to  present,  the  difficulties,  both 
near  and  remote,  which  the  frequent  lodgement  of  the  missile  among  the 
tissues  is  prone  to  create,  and  the  circumstances  in  which,  upon  the  battle- 
field, most  of  such  injuries  are  sustained. 

The  principles  of  treatment  which  are  applicable  to  contused  and  punc- 
tured wounds  in  general  find  their  most  important  application  in  the  treat- 
ment of  gunshot  wounds,  and  by  their  scrupulous  observance  the  repair  of 
these  wounds  will  be  greatly  facilitated  and  the  occurrence  of  the  wound- 
disturbances,  which  are  prone  to  manifest  themselves  as  the  sequelae  of 
gunshot  wounds,  will  be  avoided. 

HEMORRHAGE. — Special  interference  for  the  arrest  of  haemorrhage  is  only 
likely  to  be  demanded  in  the  case  of  wounds  of  vessels  of  considerable 
size  ;  in  such  cases  the  rule  is  imperative  to  enlarge  the  wound,  expose  the 
bleeding  vessel  and  ligate  it  upon  both  the  proximal  and  distal  side  of  its 
wound.  Should  the  vessel  not  have  been  already  completely  severed  by 
the  ball,  it  should  be  divided  between  the  ligatures  after  their  application. 

When  the  wound-track  is  in  the  vicinity  of  a  large  vessel,  the  possibil- 
ity of  secondary  haemorrhage  should  be  borne  in  mind,  and  special  watch 
be  kept  upon  the  case  till  its  repair  has  sufficiently  advanced  to  make  such 
danger  no  longer  to  be  apprehended. 

WOUND-CLEANLINESS. — The  cleansing  of  the  wound  involves  the  measures 
necessary  for  its  exploration,  the  removal  of  the  missile  and  other  foreign 
matter  that  may  have  been  carried  in  with  it,  and  the  destruction  of  sepsis. 


248  THE    TREATMENT    OF    WOUNDS. 

The  relative  importance  of  these  measures  appears  from  the  fact  that 
the  disastrous  results  of  gunshot  wounds,  which  are  not  quickly  fatal  from 
the  vital  importance  of  the  parts  damaged,  are  always  consequent  upon  in- 
flammatory, suppurative,  and  infective  disturbances  which  complicate  their 
repair.  These  disturbances  have  their  origin  in  septic  contamination  of 
the  wound-track,  and  gain  their  aggravated  proportions  from  the  natural 
obstacles  which  the  wound-track  presents  to  the  escape  of  the  septic  mat- 
ters afforded  by  the  contaminated  wound-secretions  and  debris. 

The  p&vention  of  the  septic  contamination  of  the  wound-tract,  therefore, 
is  to  be  considered  as  of  the  greatest  importance  to  be  observed  in  all  the 
manipulations  to  which  it  may  be  subjected,  and  is  to  be  kept  in  view 
from  the  first  moment  that  the  wound  is  received.  The  presence,  of  the 
missile,  or  other  foreign  substances  carried  in  with  it,  or  splinters  of  bone, 
are  less  to  be  feared  than  the  subsequent  admission  of  septic  elements. 
As  MacCormac  ("Antiseptic  Surgery,"  p.  268)  has  remarked,  "Gunshot 
wounds,  in  general,  present  many  features  of  what  are  called  subcutaneous 
wounds.  There  is  a  small  external  opening  which  bears  no  proportion  to 
the  extent  of  the  damage  within,  and  it  has  been  long  observed  that  some 
gunshot  fractures,  and  wounds  of  joints  even,  may  heal  just  as  simple 
fractures  do,  and  the  inference  is  that  they  healed  because  of  the  closure  of 
the  external  wound,  and  the  absence  of  suppuration  depended  on  the  non- 
admission  of  septic  elements,  at  all  events  in  sufficient  quantity  to  excite 
decomposition. " 

Immediate  antiseptic  occlusion,  that  is,  the  application  to  the  external 
wound,  or  wounds,  of  tampons  of  absorbent  antiseptic  material,  as  early  as 
possible  after  the  infliction  of  the  wound,  should  be  done ;  for  no  period  of 
time,  no  matter  how  small,  can  be  safely  allowed  to  elapse  between  the 
reception  of  the  injury  and  its  protection  from  septic  invasion.  Absorbent 
cotton  impregnated  with  iodoform,  salicylic  acid,  or  boracic  acid  may  be 
selected  for  such  immediate  occlusive  purposes.  The  antiseptic  balls 
recommended  by  Esmarch  to  be  supplied  as  a  part  of  the  outfit  of  a  soldier 
are  made  of  salicylic  wool  and  jute,  contained  in  salicylic  gauze,  and  en- 
closed in  a  square  of  oiled  paper.  The  tampon  to  be  invariably  applied 
directly  to  the  wound,  and  the  oiled  paper  used  as  an  external  covering. 
The  whole  secured  with  a  bandage. 

Jute  impregnated  with  chloride  of  zinc  has  been  recommended  for 
such  tampon  as  more  powerfully  and  certainly  antiseptic  in  its  action.  It 
may  be  applied  in  the  same  way. 


GUNSHOT   WOUNDS.  249 

When  no  antiseptic  protective  substance  is  immediately  attainable  as  a 
covering  to  the  wound,  it  should  be  left  exposed  to  the  air  without  any 
covering  whatever,  inasmuch  as  the  air  is  less  likely  to  be  septic  than  any 
ordinary  dressing  which  would  otherwise  be  applied.  By  such  exposure, 
also,  desiccation  of  the  secretions  about  the  wound  aperture  would  be 
found,  and  a  protective  crust  thus  be  formed. 

When  the  necessity  of  interference  with  the  wound  for  the  arrest  of 
haemorrhage  is  present,  its  urgency  may  compel  the  disregard  of  every 
other  precaution ;  but,  with  that  exception,  it  should  be  considered  an 
absolute  rule  that  nothing  should  be  brought  into  contact  with  it  for  any 
purpose  which  has  not  been  previously  rendered  aseptic,  and  that  all 
interference  of  any  kind  is  to  be  abstained  from  until  it  is  possible  to  sur- 
round it  with  the  necessary  provisions  against  sepsis. 

When  no  septic  matter  has  been  carried  in  with  the  bullet,  and  no 
septic  matter  has  been  introduced  by  the  surgeon  in  explorations  or  efforts 
at  removal  of  the  missile,  and  early  sealing  of  the  external  wound  has 
been  accomplished,  either  by  the  scab  formed  by  the  desiccation  of  its  dis- 
charges, or  by  occlusion  with  an  antiseptic  tampon,  the  wound  is  reduced 
to  a  subcutaneous  injury,  and  the  greater  part  of  the  difficulties  in  its 
treatment  become  eliminated. 

The  chief  obstacle  to  the  general  adoption  of  the  practice  of  primarily 
sealing  up  the  external^aperture  of  a  gunshot  wound  lies  in  the  undue  im- 
portance which  has  been  attached  to  the  early  removal  of  the  missile,  when 
embedded,  as  if  the  foreign  body  in  itself  was  the  exciting  cause  of  the 
disturbances  of  repair  that  mark  the  usual  course  of  the  healing  of  such 
wounds. 

On  the  contrary,  as  Esmarch  expresses  it,  "the  damage  done  by  the 
bullet  is  caused  by  it  hi  its  course  ;  the  harm  that  is  added  comes  mostly 
from  the  examiner's  finger." 

Beyher,1  in  detailing  the  remarkable  results  obtained,  under  his  direc- 
tion, in  the  Eusso-Turkish  war,  remarks  :  "  I  have  never  explored  for  the 
purpose  of  extracting  bullets;  never  even,  for  this  sole  purpose,  after 
patients  had  reached  the  hospital  In  the  hospital  I  have  only  removed 
them  when  their  removal  seemed  imperative  on  account  of  inflammation 
or  suppuration  in  their  immediate  vicinity.  In  a  large  number  of  cases, 
then,  the  parts  have  healed  around  the  bullet,  in  spite  of  the  generally 

1  Die  Antiseptiche  Wundbehandlung  in  der  Kriegschirurgie.  Volkmann's  SammL 
klin.  Vortrage,  No.  143,  August,  1878. 


250  THE    TREATMENT    OF    WOUNDS. 

accepted  ideas  of  practice  to  the  contrary.  It  is  not  impossible  that  in 
some  of  these  cases  the  foreign  body  may  prove  a  source  of  future  irrita- 
tion, but  its  extraction  subsequently  in  private  practice  will  be  much  less 
dangerous  than  in  the  infected  atmosphere  of  a  military  hospital,  while  its 
removal,  then,  will  be  from  tissues  which  are  no  longer  infiltrated,  and 
from  which  all  blood-extravasation  has  long  been  absorbed." 

The  mere  lodgement  of  a  bullet,  therefore,  in  the  tissues,  is  not  of  itself 
a  sufficient  indication  for  opening  up  the  wound-track  by  an  exploring 
finger  or  probe,  and  exposing  the  wound  to  the  dangers  of  septic  contam- 
ination which  such  a  manoeuvre  would  entail,  nor,  even  if  the  exploration 
was  done  with  adequate  antiseptic  precautions,  would  it  be  justifiable  to 
disturb  the  wound  by  the  new  traumatism  of  the  exploration,  until  dis- 
tinct evidence  had  appeared  that  the  missile  was  seriously  disturbing  the 
repair  of  the  wound  by  its  presence. 

IMMEDIATE  EXPLORATION  of  a  gunshot  wound  is  called  for  only  in  cases  in 
which  the  manifest  nature  of  the  wound  is  such,  by  reason  of  the  extensive 
laceration  and  destruction  of  tissue  present,  that  its  occlusion  is  impracti- 
cable, and  the  questions  of  excision  and  amputation  require  to  be  decided. 

CLASSIFICATION  OF  GUNSHOT  WOUNDS. — Gunshot  wounds  thus  divide  them- 
selves, from  the  standpoint  of  treatment,  into  two  classes :  1,  Those  which 
are  capable  of  primary  occlusion  of  the  external  wound,  and  of  conversion 
into  practically  subcutaneous  wounds ;  and,  2,  those,  which  must  be  treated 
as  open  wounds  throughout. 

By  immediate  provision  for  the  protection  of  the  wound  from  septic 
contamination  from  without,  and  by  careful  abstinence  from  any  explora- 
tions of  it,  until  the  symptoms  of  inflammatory  disturbance  declare  that 
interference  is  necessary,  an  aseptic  course  of  the  healing  of  the  wound 
may  be  secured  in  a  large  proportion  of  cases.  Keyher,  in  his  observations 
before  alluded  to,  has  recorded  the  following  valuable  statistics  of  the  com- 
parative safety  and  value  of  such  attempts  to  occlude  gunshot  wounds. 

Out  of  twenty-eight  cases  of  gunshot  wound  of  the  knee  with  bullet 
embedded  in  the  part,  the  four  which  were  treated  in  accordance  with  these 
principles,  from  the  outset,  recovered  with  movable  joints  ;  eight,  in  which 
antiseptic  precautions  were  not  adopted  until  the  next  day,  died,  as  well  as 
four  which  had  no  such  treatment  at  all ;  while  of  the  remaining  twelve, 
which  had  no  primary  antiseptic  treatment,  and  required  either  interme- 
diate or  secondary  amputation,  eleven  died.  Of  forty-six  cases  of  wounds 
of  different  joints  treated  as  above,  six  died — mortality  13  per  cent  ;  of 


PRIMAEY    ANTISEPTIC    DECLUSION.  251 

\ 
these,  nineteen  required  primary  resection,  of  which  only  two  died — 10.5 

per  cent.  Of  seventy-eight  cases  similar  in  other  respects,  but  in  which 
antisepsis  was  a  secondary  consideration,  or  from  which  bullets  had  been 
extracted,  forty-eight  died — 61.5  per  cent  Of  another  series  of  sixty-two 
shot  wounds  of  joints  without  primary  precautions,  thirty-nine  died — 63 
per  cent.  So  in  cases  of  shot  fractures  of  long  bones,  of  sixty-five  treated 
from  the  first,  only  five  died — 7.6  per  cent.  Of  twenty-nine  not  so  treated, 
eight  died — 27  per  cent.  In  a  neighboring  hospital  to  his  own,  during 
the  campaign  in  the  Caucasus,  Keyher  saw  seven  cases  of  uncomplicated 
wounds  of  soft  parts  die  of  pyaemia  ;  under  his  own  primary  antiseptic 
measures  he  lost  but  one  such.  In  another  series  of  sixty-five  fractures 
treated  secondarily  by  antiseptic  rules,  twenty-three  died — 35.3  per  cent. 
As  illustrating  the  reduced  number  of  cases  of  pyaemia,  altogether  of 
eighty-one  cases  of  miscellaneous  wounds  treated  primarily,  only  five  died 
from  blood-poisoning — 6. 1  per  cent  ;  whereas,  of  one  hundred  and  forty- 
three  not  so  treated,  forty-six  died — 32. 1  per  cent.  Of  fifty-seven  various 
wounds  of  skull,  buttocks,  and  soft  parts,  all  treated  antiseptically  from  the 
start,  not  one  died. 

With  all  his  cases,  Beyher  saw  erysipelas  but  three  times.  There  were, 
moreover,  but  two  cases  of  tetanus,  and  none  of  gangrene.  The  number 
of  lives  saved  by  the  adoption  of  this  method  by  Reyher  was,  therefore,  in 
proportion,  from  three  to  four  times  as  many  as  were  saved  under  the 
older  methods.  Out  of  the  forty-six  cases  of  gunshot  wounds  of  joints  it 
was  only  necessary  in  four  cases  to  depart  from  the  system  of  primary 
occlusion  without  interference  ;  whereas,  of  seventy-five  cases  of  similar 
wounds  treated  by  secondary  antisepsis,  drainage,  etc.,  in  fifty-four  of  them 
resections  or  amputations  were  required. 

The  second  class  of  cases,  which  must  be  treated  as  open  wounds,  in- 
clude those  in  which  the  extent  of  the  external  wound  is  too  great  to  give 
any  hope  of  securing  its  primary  occlusion,  those  in  which  these  attempts 
have  been  made  but  have  failed,  and  those  in  which  such  attempts  have 
been  deferred  or  omitted  until  the  wound  has  become  manifestly  septic, 
by  reason  of  its  exposure,  its  having  been  subjected  to  uncleanly  and  pre- 
mature explorations,  or  the  application  to  it  of  contaminated  dressing. 

Even  in  this  second  class  of  cases,  all  explorations  and  other  operative 
measures  should  be  deferred  until  they  can  be  done  with  the  necessary 
precautions  against  septic  contamination,  or  can  be  accompanied  by  ade- 
quate protective  antiseptic  dressing. 


252  THE    TREATMENT    OF    WOUNDS. 

TREATMENT  OF  OPEN  GUNSHOT  WOUNDS. — The  treatment  of  this  class  of 
gunshot  wounds  should  be  conducted  with  scrupulous  attention  to  the 
thorough  disinfection  of  every  accessible  recess  of  the  wound  and  to  per- 
fect freedom  of  drainage.  The  appearance  of  high  fever,  inflammatory 
swelling,  progressive  infiltration,  gangrene,  and  other  evidences  of  progres- 
sive septic  contamination,  call  for  the  energetic  and  thorough  application 
of  all  the  resources  for  the  destruction  or  control  of  sepsis  which  are  within 
the  command  of  the  surgeon. 

The  primary  examination  and  cleansing  of  the  wound  should  be  con- 
ducted with  the  view  of  making  it  aseptic.  Frequent  partial  cleansing 
should  be  avoided  ;  repeated  probings,  cuttings,  irrigations,  and  squeezings 
for  the  purpose  of  evacuating  wound-secretions  and  debris,  which  keep  up 
a  continual  irritation  of  the  wound,  should  be  replaced  by  a  thorough  pri- 
mary examination  and  cleansing.  This  must  be  conducted  with  delibera- 
tion and  minute  attention  to  the  ultimate  object  in  view — the  destruction 
and  prevention  of  sepsis.  An  anaesthetic  should  be  administered,  and 
everything  brought  in  contact  with  the  wound  should  be  carefully  disin- 
fected as  used  (see  Chapters  IV.  and  VUL). 

The  external  wound  should  be  freely  enlarged,  when  necessary,  so  as 
to  permit  the  introduction  of  the  cleansed  and  disinfected  finger  for  pur- 
poses of  exploration.  For  the  purpose  of  enlarging  the  deeper  part  of  the 
track,  if  the  vicinity  of  important  organs  or  the  dangers  of  haemorrhage 
make  the  use  of  the  knife  undesirable,  it  may  be  enlarged  with  blunt  in- 
struments, as  dressing  forceps  introduced  closed  and  then  opened  and 
withdrawn,  thus  acting  as  a  dilator.  The  ordinary  glove-stretcher  sug- 
gests itself  as  a  model  for  such  a  dilating  forceps. 

Bullets,  splinters  of  bone  entirely  detached,  pieces  of  clothing,  and 
other  foreign  bodies,  which  are  found  during  the  examination,  should  be 
carefully  extracted. 

A  bullet  not  infrequently,  after  having  in  the  early  part  of  its  course 
inflicted  injuries  which  require  to  be  treated  by  the  open  method,  con- 
tinues its  course  in  such  a  manner  that  the  second  part  of  its  track  may 
heal  primarily  behind  it,  and  the  bullet  remain  shut  off  from  the  first  part 
of  the  wound,  and  then,  becoming  encysted,  permanently  remain  without 
inducing  further  mischief. 

The  treatment  of  such  a  deep  wound-track  should  be  conducted  on  the 
same  principles  as  those  which  control  the  treatment  of  the  more  superfi- 
cial wound.  It  should  not  be  probed,  nor  irrigated,  nor  in  any  manner  in- 


PROBES    AND    PROBING.  253 

terfered  with,  until  evidences  of  inflammatory  disturbance  of  its  walls  ap- 
pear. No  search  should  be  made  along  it  for  the  bullet,  much  less  should 
the  mere  presence  of  the  bullet  at  its  bottom  be  considered  an  indication 
for  an  attempt  at  its  removal  The  disinfection  and  drainage  of  the  super- 
ficial portion  of  the  wound  should  be  conducted  with  all  care  and  thor- 
oughnesa  Should  disturbances  of  the  deeper  portions  of  the  wound  mani- 
fest themselves,  the  exploration,  cleansing,  and  drainage  of  that  portion  of 
the  wound  would  then  be  required.  Enlargement  of  the  aperture  of  com- 
munication with  the  superficial  wound,  and  free  counter-incisions  to  the 
extent  required  for  its  easy  and  perfect  drainage,  and  for  the  removal  of 
any  foreign  and  irritating  bodies  along  its  track  will  be  necessary. 

Probes. — For  the  exploration  of  wounds,  the  depth  or  course  of  which 
is  such  as  to  make  them  inaccessible  to  the  finger,  probes  must  be  used. 

For  probing,  a  blunt-pointed,  flexible  rod  should  be  used  ;  the  probing 
extremity  should  be  sufficiently  large,  so  that  it  should  not  easily  make  a 
passage  for  itself  among  the  tissues  ;  the  shaft  should  be  flexible,  so  that  it 
may  be  adapted  to  the  particular  course  of  the  track  that  is  being  ex- 
plored, and  should  be  long  enough  to  admit  of  being  easily  and  definitely 
controlled  by  the  hand  of  the  surgeon. 

Rods  of  copper,  silver,  or  pewter,  a  foot  in  length,  with  bulbous  ex- 
tremities of  the  diameter  of  an  ordinary  goose-quill,  offer  themselves  as 
suitable  material  for  probes.  In  an  emergency  the  ingenuity  of  the  sur- 
geon will  not  fail  to  find  some  material  from  which  a  probe  may  be  extem- 
porized, although  adherence  to  the  rules  which  should  guide  the  treatment 
of  wounds,  as  given  above,  will  remove  explorations  altogether  from  the 
list  of  operations  of  emergency. 

Probing  a  wound  should  be  done  with  all  possible  gentleness  and  care. 
The  probe  should  be  carefully  cleansed  and  disinfected  at  the  time  of 
being  used.  It  cannot  be  too  strongly  impressed  on  the  mind  of  the  sur- 
geon, however,  that  all  probing  of  a  wound  should  be  abstained  from  until 
such  time  as  the  final  thorough  examination  and  dressing  of  the  wound 
can  be  performed,  when,  once  for  all,  the  use  of  the  probe  may  be  required 
in  accordance  with  the  restricted  indications  for  its  use  which  have  been 
mentioned. 

The  Removal  of  Bullets. — When  relegated  to  its  proper  place  as  a  minor 
part  of  the  general  provisions  for  obtaining  wound-cleanliness,  the  search 
for  and  the  removal  of  the  bullet  calls  for  less  consideration  as  to  the 
methods  by  which  it  may  be  accomplished,  and  the  apparatus  needed  for 


254  THE    TREATMENT    OF    WOUNDS. 

its  technique,  than  when  it  was  esteemed  in  itself  an  indication  of  first 
importance  to  be  met  Forceps  with  slender  and  firm  jawc,  with  slightly 
projecting  teeth  that  may  increase  the  security  of  the  grasp  of  the  forceps 
upon  the  bullet^  will  facilitate  the  removal  of  a  bullet  when  exposed.  A 
blind  groping  for  a  bullet  at  the  bottom  of  a  deep  sinus  should  not  be 
attempted  ;  the  enlargement  of  the  external  aperture,  and  the  dilatation  of 
the  deeper  track,  as  required  for  the  purposes  of  cleansing  and  drainage 
of  a  wound,  or  the  counter-incisions  made  when  the  length  and  location  of 
the  track  demand  it,  should  be  ample  enough  to  permit  the  sufficient 
exposure,  and  ready  seizure  of  the  bullet,  if  it  is  to  be  removed  at  all 

When  the  ball  is  suspected  of  having  become  impacted  in  a  bone,  or  to 
have  penetrated  a  joint,  it  is  not  to  be  interfered  with,  nor  is  an  exploration 
for  the  purpose  of  determining  the  fact  to  be  made,  unless  the  wound,  for 
other  reasons,  demands  treatment  as  an  open  wound,  or  the  efforts  to 
secure  primary  occlusion  have  failed.  If,  upon  exposure,  it  is  loosely  held, 
it  may  be  readily  removed  ;  if  firmly  impacted,  it  may  be  loosened  by 
means  of  an  elevator  or  chisel,  and  then  removed. 

IMMOBILIZATION  of  parts  which  are  the  subjects  of  gunshot  wounds  is  of 
extreme  importance.  Means  of  immobilization  should  be  adopted  as  a 
part  of  the  first  dressing,  it  should  be  made  continuous  and  absolute,  and 
will  prove  a  powerful  accessory  to  the  local  antiseptic  dressings  in  securing 
permanent  primary  occlusion  of  a  wound. 

Aside  from  penetrating  wounds  of  the  cavities  of  the  body,  and  injuries 
of  the  large  vessels,  the  great  majority  of  those  gunshot  wounds  which  are 
likely  to  be  complicated  by  dangerous  wound-disturbances  are  those  which 
involve  bones  and  joints.  The  further  consideration  of  the  special  methods 
of  averting  or  controlling  the  dangers  incident  to  such  wounds  belongs 
naturally  to  the  discussion  of  that  class  of  wounds  in  general 


CHAPTER  XY. 

EXTERNAL    WOUNDS    COMMUNICATING    WITH    FRACTURES    OF 
BONES  AND    WITH   JOINT    CAVITIES. 

Peculiarities — Value  of  Antiseptic  Methods  of  Treatment— MacCor mac — Classification 
— Recent  Injuries  with  Slight  External  Wound — Primary  Antiseptic  Occlusion — 
Recent  Injuries  with  External  Wound  of  Considerable  Extent — Primary  Explora- 
tion and  Cleansing — Counter-incisions — Splinters  of  Bone — Drainage — Suture — 
Wounds  of  Joints — Incisions — Partial  Resections — Protective  Dressings — Immo- 
bilization— After-treatment — Injuries  not  Recent  and  Septic — Favorable  Cases- 
Cases  with  Pronounced  Septic  Infection — Disinfection — Immobilization — Fenes- 
trated  and  Interrupted  Plastic  Splints — Honeycomb  Plaster  Splint. 

THE  conditions  presented  by  those  lacerated  and  contused  wounds,  which 
axe  complicated  by  fractures  of  bones  communicating  with  the  wound,  are 
such  as  are  very  favorable  to  the  development  of  septic  disturbances  in 
their  most  aggravated  form.  Phlegmonous  inflammation,  prolonged  sup- 
puration, more  or  less  sloughing  of  the  contused  and  lacerated  tissues,  and 
necrosis  of  bone,  are  the  ordinary  attendants  of  the  healing  of  such 
wounds  when  adequate  precautions  against  sepsis  are  not  observed  in  their 
treatment ;  while  in  this  class  of  injuries,  more  than  in  any  other,  have  the 
more  formidable  septic  complications  of  erysipelas,  gangrene,  septicaemia, 
and  pyaemia  been  rife. 

The  special  feature  possessed  by  these  wounds  which  tends  to  aggra- 
vate the  difficulties  attending  the  treatment  of  severe  lacerated  and  con- 
tused wounds  in  general,  is  the  irritation  of  the  wound  by  the  movements 
of  the  bone  fragments  within  it.  The  law  of  rest  is  thereby  continually 
being  violated,  and  a  favorable  condition  for  the  development  of  septic 
disturbances  maintained. 

The  treatment  of  these  cases  should  be  conducted  from  the  first  in  such 
a  way  as  to  prevent,  if  possible,  septic  contamination,  or  to  destroy  or  con- 
trol it,  when  efforts  at  primary  prevention  have  not  been  made,  or  have 
failed. 


256  THE   TREATMENT    OF    WOUNDS. 

"In  no  kind  of  surgical  injury,"  to  borrow  the  language  of  MacCormac 
("Antiseptic  Surgery,"  p.  180),  "  have  the  results  accomplished  by  the  anti- 
septic method  been  more  thoroughly  satisfactory  and  complete  than  in 
compound  fracture.  In  future  we  may  expect  to  save  the  limb  of  the 
patient  in  all  cases  in  which  the  extent  of  damage  to  the  soft  parts,  vessels, 
and  nerves  is  not  such  as  to  absolutely  forbid  the  attempt.  Even  in  cases 
where  the  expectation  of  saving  the  limb  is  not  great,  we  are  justified  in 
giving  the  patient  the  benefit  of  the  doubt,  as  we  do  not  endanger  his  life 
by  so  doing ;  and  should  gangrene  or  any  necessity  for  operation  occur, 
we  may  then  amputate  without  increased  risk 

"  Pyaemia  and  septicaemia,  which  have  hitherto  caused  half  the  deaths 
among  the  fatal  cases,  should  no  longer  occur ;  but  only  death  from  un- 
avoidable causes,  such  as  fat-embolism,  delirium  tremens,  tetanus,  senile 
bronchitis — causes  not  directly  dependent  upon  the  wound  nor  its 
treatment" 

The  difficulties  which  will  attend  the  treatment  of  these  cases  will 
depend  on  the  extent  and  character  of  the  traumatism  which  has  been 
inflicted,  and  upon  the  time  at  which  they  came  under  the  care  of  the 
surgeon. 

For  purposes  of  convenient  consideration  they  may  be  classified  into 
three  groups  :  1.  Cases  in  which  the  injury  is  recent,  and  in  which  the 
external  wound  is  a  slight  puncture  only  of  the  skin.  2.  Cases  in  which  the 
injury  is  recent,  and  in  which  the  external  wound  is  of  considerable  extent. 
3.  Cases  which  are  not  recent,  and  which  have  already  become  septic.  For 
each  of  these  groups  of  cases  a  different  mode  of  procedure  offers  the 
best  results  ;  for  the  first,  primary  occlusion,  as  in  gunshot  wounds  ;  for 
the  second,  thorough  primary  disinfection  of  the  whole  extent  of  the 
wound,  removal  of  blood-clots  and  loose  splinters  of  bone,  drainage,  and 
finally  occlusion  by  a  closely  fitting  and  evenly  compressing  antiseptic 
protective  dressing  ;  for  the  last,  abandonment  of  occlusive  dressings,  and 
the  substitution  of  open  methods  of  treatment,  with  antiseptic  irrigation. 

Each  of  these  groups  requires  consideration  more  in  detail 

RECENT  INJURIES  WITH  SLIGHT  EXTERNAL  WOUND. 

When  but  a  short  time — an  hour  or  two — has  elapsed  since  the  recep- 
tion of  the  injury ;  when  the  wound  through  the  integument  is  small ; 
when  there  is  no  subcutaneous  cavity  filled  with  coagula,  and  the  adjacent 


COMPOUND    FRACTURES.  257 

tissues  are  not  swollen  and  infiltrated,  there  is  every  reason  to  expect  that 
by  cleansing  the  external  wound  and  the  adjacent  skin,  by  occluding  the 
wound  with  an  absorbent  antiseptic  dressing,  and  by  keeping  the  parts  at 
perfect  rest,  undisturbed  and  speedy  healing  of  the  external  wound  would 
be  secured  and  the  deeper  injuries  be  reduced  to  the  condition  of  subcu- 
taneous injuries.  All  explorations  of  such  an  injury  should  be  carefully 
refrained  from. 

The  comminution  of  the  bone,  and  the  presence  of  splintered  fragments 
at  the  bottom  of  the  wound  is  not  in  itself  sufficient  to  constitute  an  ex- 
ception to  this  practice.  Examples  of  such  comminution  of  bone,  with 
small  external  wound,  are  confined  almost  entirely  to  cases  of  gunshot  in- 
juries. Bruns,1  in  connection  with  this  subject,  remarks  that  even  when 
splinters  have  become  entirely  detached  and  robbed  of  their  periosteum, 
•they  will  grow  together  again,  provided  suppuration  is  prevented  and 
primary  union  of  the  external  wound  is  secured.  A  splinter,  even  if  the 
source  of  mechanical  irritation,  is  not  to  be  regarded  as  in  itself  an  element 
inducing  inflammation.  The  aspect  of  the  case  would,  however,  be 
changed  if  the  foreign  body,  which  had  produced  the  splintering,  had 
brought  with  it  septic  germs  so  as  to  infect  the  wound.  The  rule  laid 
down  for  the  treatment  of  gunshot  wounds  in  general,  that,  where  the  in- 
jury is  not  such  as  to  manifestly  require  primary  amputation,  the  wound 
should  be  treated  from  the  beginning  by  antiseptic  occlusion  and  perfect 
rest,  without  exploration  and  enlarging,  applies  equally  to  wounds  compli- 
cated by  fracture  of  bone,  however  extensive  the  comminution  may  be. 

The  treatment  required  should  be  begun  by  a  careful  cleansing  and 
disinfection  of  the  skin  over  a  large  area  surrounding  the  wound.  Carbolic 
acid  or  corrosive  sublimate  lotions  may  be  used  for  this  purpose.  The 
external  wound  should  be  irrigated  with  the  same  lotion,  and  should  then 
be  covered  with  thick  layers  of  antiseptic,  absorbent,  and  protective  mate- 
rial (Chapter  X.).  lodoform  absorbent  gauze,  or  cotton  wool,  presents  the 
greatest  advantages  for  this  dressing ;  but  many  other  substances,  as  the 
carbolic,  naphthalin,  and  corrosive  sublimate  dressings  will  likewise  be 
efficient.  The  dressing  will  be  completed  by  a  bandage  of  fixation  and 
compression,  and  the  application  of  an  immobilizing  apparatus. 

As  long  as  no  symptoms,  general  or  local,  of  wound  disturbance  mani- 
fest themselves,  the  dressing  should  be  left  undisturbed.  When  sufficient 


1  Die  aUgemeine   Lehre  von  den  KnocJienbruchen.     Deutsclie  Chirurgie,  Lief.  27, 

1  Halfte,  p.  358. 
17 


258  THE    TREATMENT    OF    WOUNDS. 

time  for  complete  healing  of  the  wound  has  elapsed,  the  wound-dressings 
may  be  removed,  and  the  further  treatment  of  the  case  be  as  for  a  simple 
fracture. 

Should  inflammatory  disturbance  in  any  degree  manifest  itself,  the 
attempt  at  primary  occlusion  must  be  abandoned,  and  the  cleansing,  dis- 
infection, and  after-treatment  of  the  wound  be  conducted  as  in  the  more 
severe  cases  next  to  be  discussed. 


RECENT    INJURIES,    WITH    EXTERNAL    WOUND    OF     CONSIDERABLE 

EXTENT. 

The  painful  and  protracted  character  of  the  manipulations  required  in 
the  first  dressing  of  this  class  of  cases  make  the  administration  of  an  an- 
aesthetic indispensable.  Every  portion  of  the  skin  which  will  be  included 
in  the  subsequent  dressings  must  be  thoroughly  cleansed  de  rigueiir  (Chap- 
ter VUL ),  with  soap  and  water,  brush  and  razor,  and  finally  purified  with 
a  carbolic  acid  or  corrosive  sublimate  lotion.  Tlie  wound  cavity  is  next  to 
be  disinfected.  If  the  existing  opening  is  not  large  enough  to  permit  the 
full  exploration  of  the  wound  by  the  finger,  and  by  retraction  of  its  margins 
to  permit  inspection  of  all  parts  of  the  wound-cavity,  it  must  be  enlarged 
by  the  knife.  All  coagula  and  foreign  matter  are  removed,  and  the  wound 
cavity  is  then  thoroughly  irrigated  with  an  antiseptic  solution.  The  follow- 
ing more  detailed  directions  for  accomplishing  the  complete  disinfection 
of  the  wound  are  given  by  Bruns  (loc.  cit),  from  whose  work,  also,  the 
greater  part  of  what  follows  in  the  present  chapter  has  been  appropriated. 

If  long  sinuses  and  pockets  are  present,  counter-incisions  should  be 
made,  so  as  to  open  them  at  their  farther  end,  and  secure  through  drain- 
age in  them.  If  extensive  detachments  of  the  skin  are  detected,  numerous 
small  incisions  are  recommended  for  the  insertion  of  small  draina  If  the 
wound-opening  is  unfavorably  situated  for  its  enlargement,  so  that  satis- 
factory disinfection  of  the  breach,  caused  by  the  fracture,  is  hindered,  as 
is  the  case  sometimes  in  gunshot  fractures,  a  drain  should  be  introduced 
at  the  original  aperture,  and  a  counter-incision  made  into  the  wound-track, 
where  it  is  most  superficial,  through  which  the  disinfection  may  be  per- 
formed. If  it  is  discovered,  on  digital  examination,  that  beyond  the  frag- 
ments pockets  have  formed,  the  bone  at  the  point  of  fracture  must  be  bent 
and  its  fractured  ends  forced  up  through  the  wound  sufficiently  to  permit 
such  deep  recess  to  be  irrigated.  Excision  of  badly  lacerated  and  contused 


COMPOUND    FRACTURES.  250 

portions  of  soft  tissue  may,  in  some  cases,  be  done  with  the  scissors,  when 
it  is  probable  that  the  healing  of  the  wound  will  be  accelerated  thereby. 

All  splinters  and  fragments  of  bone  which  have  become  completely  de- 
tached from  the  soft  parts,  or  which  are  held  only  by  a  small  strip  of  peri- 
osteum or  muscular  fibre,  as  a  rule,  should  be  removed,  since  these  frag- 
ments obstruct  healing  whenever  suppuration  and  sepsis  infest  the  wound, 
an  occurrence  which  cannot  always  be  avoided.  When  drainage  will  be 
facilitated,  fragments  of  bone  may  be  removed,  even  when  more  exten- 
sively adherent  to  the  soft  tissues.  In  this  case  the  periosteum  should  be 
carefully  preserved  by  using  a  periostea!  scraper  to  detach  the  bone. 
Portions  of  periosteum,  thus  saved,  will  be  of  great  value  as  sources  of 
callus.  All  fragments  of  bone  adhering  to  wide  strips  of  soft  tissue  should 
be  replaced  in  their  normal  position  ;  their  union  may  be  expected  with 
certainty  if  the  wound  be  kept  aseptic  during  its  healing. 

Next  follows  the  drainage  and  the  suture.  Multiple  short  drains  should 
be  introduced  into  the  wound  ;  those  in  the  principal  wound  should  reach 
down  to  the  point  of  fracture  in  the  bone,  but  should  never  penetrate  be- 
tween the  fragments.  All  the  drainage-tubes  should  be  clipped  to  the 
surface  of  the  skin,  and  fixed  by  a  safety-pin  transversely  inserted.  All 
the  wounds  of  counter-incision,  as  well  as  the  principal  wound,  should 
then  be  sutured  close  to  the  drainage-tubes,  whenever  healing  by  first  in- 
tention appears  possible. 

The  treatment  now  detailed  is  to  be  employed  not  only  when  the  wound 
communicates  with  a  fracture  of  the  shaft  of  a  bone,  but  also  when  a  joint 
cavity  is  opened  into  by  the  wound. 

If  the  joint  is  not  opened  by  a  direct  penetrating  wound,  but  only  by  a 
fissure  through  the  articular  extremities  of  the  bones  forming  the  joint — 
an  occurrence  which  may  be  verified  by  the  haemorrhage  into  the  joint — 
the  joint  cavity  should  be  opened  by  a  free  incision  at  a  suitable  point,  and 
should  be  emptied  of  all  serum  and  coagula,  disinfected  and  drained.  In 
given  cases,  the  procedure  amounts  to  nothing  more  nor  less  than  a  partial 
and  irregular  resection  of  the  joint,  the  features  of  which  will  suggest  them- 
selves in  the  special  conditions  which  these  wounds  will  present  in  which 
antiseptic  conservative  methods  will  hereafter  be  more  frequently  adopted. 
Total  resection  will  be  limited,  henceforth,  to  very  grave  cases. 

After  this  primary  cleansing  and  disinfection  of  the  wound  has  been 
thoroughly  accomplished,  a  protective  antiseptic  dressing  should  be  applied 
with  great  care,  and  made  to  extend  widely  in  every  direction  beyond  the 


260  THE   TREATMENT    OF    WOUNDS. 

wound.  Gauze,  or  other  absorbent  material,  impregnated  with  carbolic 
acid,  iodoform,  corrosive  sublimate,  naphthalin,  or  other  antiseptic  sub- 
stance (Chapter  X.),  should  be  applied,  crumpled  and  in  multiple  layers, 
and  confined  with  an  accurately  applied  roller  bandage,  so  as  to  act  as  a 
means  both  of  protection  and  compression. 

Difficulties  will  arise  if  the  wound  is  in  such  proximity  to  the  thorax 
that  the  dressings  extend  upon  it,  since  the  movements  of  respiration  will 
loosen  the  dressing.  Martin's  pure  rubber  bandage  will  be  of  especial 
service  in  such  cases,  accomplishing  both  the  exclusion  of  air  and  com- 
pression. 

The  part  is  finally  immobilized  by  the  application  of  a  proper  splint. 

The  after-treatment  is  very  simple,  provided  thorough  asepsis  has  been 
obtained.  In  favorable  cases,  where  healing  by  first  intention  is  secured,  a 
single  change  of  dressing,  after  six  to  eight  days,  for  the  removal  of  su- 
tures and  drainage-tubes,  is  all  that  is  necessary.  The  second  dressing  re- 
mains to  the  time  of  complete  healing.  In  ordinary  cases,  where  the 
wound  does  not  show  a  tendency  to  primary  union,  the  dressing  is  changed 
in  from  two  to  four  days,  according  to  the  discharge  ;  later,  when  the  se- 
cretions become  of  a  thick  creamy  consistence,  the  intervals  between  the 
dressings  will  be  longer.  Each  change  of  dressing  should  be  executed 
with  rapidity,  and  yet  with  the  greatest  care.  Exquisite  caution  should  be 
exercised  in  the  examinations  and  irrigations  of  the  wound.  The  manipu- 
lations should  be  restricted  to  simply  cleaning  the  surrounding  integument 
with  a  pledget  of  absorbent  cotton  moistened  with  an  antiseptic  lotion, 
being  careful  not  to  disturb  its  relations.  The  drains  should  be  removed 
as  soon  as  the  secretions  cease  to  flow  through  them.  The  dressings 
should  be  renewed  till  the  wound  is  filled  with  granulations  up  to  the  level 
of  the  surrounding  skin.  It  will  then  suffice  to  apply  a  more  simple  pro- 
tective dressing,  covered  by  a  plastic  splint,  as  in  subcutaneous  fractures, 
till  consolidation  has  taken  place. 

INJURIES,    NOT   RECENT,   AND   SEPTIC. 

As  injuries  which  are  "  not  recent "  are  to  be  comprehended  those 
which  come  under  treatment  after  the  lapse  of  twenty-four  hours.  The 
task  to  establish  an  aseptic  course  in  these  cases  is  obviously  much  more 
difficult ;  each  patient,  however,  will  present  its  special  conditions,  so  that 
we  have  here,  also,  to  differentiate  between  favorable  and  unfavorable 
cases,  each  kind  requiring  different  treatment 


SEPTIC    COMPOUND    FRACTURES.  201 

The  more  favorable  cases  are  those  which  do  not  show  an  extended 
wound-reaction,  even  though  unmistakable  signs  of  decomposition  of  the 
wound-secretions  are  present  According  to  past  experience,  an  aseptic 
course  may,  even  under  these  conditions,  be  obtained — i.e.,  an  undisturbed 
healing  by  granulation,  though  frequently  with  increased  suppuration,  and 
often  with  necrosis  of  the  ends  of  the  fractured  bone.  The  method  to  be 
pursued  in  these  cases  is  virtually  the  same  as  in  recent  wounds — namely, 
enlargement,  exploration,  and  disinfection  of  the  wound,  with  subsequent 
antiseptic,  protective,  and  occlusive  dressings. 

Contrasted  with  these  favorable  cases  are  to  be  placed  those  in  which 
the  pronounced  picture  of  local  sepsis  is  presented,  either  in  consequence 
of  neglect  of  antiseptic  treatment,  or  of  the  inefficiency  of  that  which  has 
been  employed.  In  these  cases  will  be  observed  positive  signs  of  decom- 
position of  the  wound-secretions,  real  ichorous  discharge,  more  or  less  in- 
flammatory reaction  in  the  surroundings  of  the  wound,  in  some  cases  gan- 
grene of  the  badly  contused  soft  parts,  and  progressive  infiltration  of  the 
connective  tissue  with  pus  and  gas. 

Energetic  disinfection  is  again  demanded  in  these  cases,  though  unde- 
niably attended  with  greater  difficulty,  and  not  in  all  cases  possible  to  be 
absolutely  attained.  All  septically  infected  tissues  must  be  freely  laid 
open  by  incisions,  so  as  to  give  entrance  to  the  disinfecting  substance  ;  all 
gangrenous  tissues  mast  be  removed  with  knife  and  scissors.  Long  inci- 
sions and  counter-incisions  should  be  made  to  open  up  the  torn  and  infil- 
trated interstices  of  the  muscular  tissue.  Where  there  is  extensive  subcu- 
taneous infiltration  of  blood,  as  well  as  in  those  cases  in  which  there  is 
already  present  phlegmonous  infiltration,  numerous  small  incisions  should 
be  made,  in  addition,  through  the  integument,  for  the  removal  of  blood, 
pus,  and  gases,  and  to  enable  the  disinfecting  fluid  to  be  introduced  in  as 
many  places  as  possible.  These  multiple  scarifications  will  render  impor- 
tant service  in  opening  the  spaces  between  the  long  incisions.  They  should 
all  be  subjected  to  thorough  antiseptic  irrigation,  and  be  kept  open  by 
small  drainage-tubes. ' 

Neither  occlusion  nor  compression  of  the  wound  can  be  adopted  in 
such  cases,  while  it  is  further  important  that  the  changes  which  may  be 
going  on  in  it  be  capable  of  being  observed  at  any  time.  For  these  rea- 
sons an  open  treatment,  with  permanent  antiseptic  irrigation  is  required 
(Chapter  XH). 

This  treatment  should  be  continued  until  the  wound  has  been  rendered 


262  THE    TREATMENT    OP   WOUNDS. 

perfectly  aseptic,  when  it  may  be  replaced  by  occlusive  and  compressive 
antiseptic  dressings. 

IMMOBILIZATION  OF   THE  INJURED  PARTS. 

Means  of  immobilization  must  be  resorted  to  both  for  the  protection 
of  the  injured  soft  parts,  and  for  the  retention  of  the  bone-fragments  in 
proper  position  until  consolidation  has  been  accomplished.  The  presence 
of  an  open  wound  introduces  elements  of  greater  difficulty  into  the  prob- 
lem of  immobilization  than  when  a  simple  fracture  is  being  dealt  with,  for, 
either  the  fracture-dressing  must  be  removed  every  time  the  wound  is  ex- 
amined, and  then  renewed,  or  must  be  so  constructed  as  to  leave  exposed 
the  wound  and  its  surroundings.  The  latter  plan  is  to  be  preferred,  but 
is  attended  by  greater  technical  difficulties,  which  grow  with  the  circumfer- 
ence of  the  wound,  and  may  be  insurmountable  in  very  extensive  or  multi- 
ple wounds. 

The  difficulties  attending  the  employment  of  permanent  dressings  is 
quite  apparent  when  antiseptic  dressings  also  are  to  be  used,  and  the  ques- 
tion may  have  to  be  decided  which  of  the  two  factors,  antisepsis  or  immo- 
bilization, is  of  the  greater  importance,  and  which  shall  be  infringed  upon 
in  their  combination. 

Slight  motion  of  the  extremities  of  the  fractured  bone,  during  a  change 
of  dressing,  is  not  followed  by  any  reaction  when  the  parts  are  kept 
aseptic.  Antisepsis,  therefore,  is  the  first  requirement  to  be  observed, 
especially  in  the  earlier  period  of  the  case,  until  the  fracture  and  the 
wound  in  the  soft  parts  are  covered  with  granulationa  Antisepsis  should 
be  maintained  scrupulously,  even  if  it  becomes  necessary  to  remove  the 
fracture-dressing  from  the  limb  to  change  the  antiseptic  dressing. 

Except  in  the  more  simple  and  favorable  cases  the  use  of  a  permanent 
plaster-of-Paris  dressing,  applied  so  as  to  encircle  the  limb,  and  f  enestrated, 
is  not  compatible  with  the  requirements  of  the  antiseptic  dressing  of  the 
wound  during  the  earlier  days  of  its  course.  After  the  first  critical  period 
has  passed,  however,  and  the  wound  has  become  covered  with  granula- 
tions, and  the  amount  of  its  secretions  have  somewhat  diminished,  such  a 
dressing  will  be  applicable.  In  cases  of  fractures  occurring  in  patients 
suffering  from  delirium  tremens,  this  dressing  is  indispensable. 

During  the  first  period  of  the  treatment  of  these  injuries,  only  such  a 
means  of  immobilization  should  be  employed  as  will  allow  the  wound  to 
be  enwrapped  with  an  antiseptic  dressing  that  will  extend  over  a  wide  cir- 


IMMOBILIZING    COMPOUND    FRACTURES. 


263 


cumference  about  it.  Not  always  the  same  kind  of  dressing  will  answer ; 
the  seat  of  the  fracture,  and  the  special  conditions  of  each  case  should  be 
our  guide. 

Plastic  splints  are  to  be  recommended  in  most  cases.  Splints  made  of 
pasteboard,  felt,  or  plaster-of-Paris  are  especially  applicable,  as  they  can 
be  adapted  to  any  part  of  the  body.  The  width  of  the  splint  should  ex- 
tend over  about  one-third  of  the  circumference  of  the  limb.  In  general, 
the  splint  is  applied  over  the  antiseptic  dressing,  if  possible,  on  that  side 
of  the  limb  where  it  will  be  least  soiled  by  the  wound- secretions.  They 
should  be  secured  by  moist  starched  bandages,  so  that  the  turns,  when  dry, 
will  firmly  adhere  to  each  other.  For  suspending  the  limb,  holes  may 
be  punched  in  the  splint,  and  cords  for  suspension  drawn  through 
them. 


Fio.  88. — Bowed  Plaster  Splint  for  Compound  Fracture  of  the  Knee-joint  (Beely). 

Such  splints  can  easily  be  removed  at  each  change  of  the  dressing.  In 
some  cases,  however,  in  which  the  wound  is  not  too  large,  and  is  favorably 
located,  the  splint  might  be  enclosed  within  the  antiseptic  dressing,  so 
that  it  might  remain  when  the  latter  is  changed.  In  such  a  case,  the 
splint  should  be  narrowed  opposite  the  wound,  and  wrapped  in  impermea- 
ble tissue  or  lined  with  antiseptic  cotton.  It  may  then  be  placed  directly 
upon  that  part  of  the  limb  opposite  the  wound,  next  to  the  skin.  Over  aU, 
the  antiseptic  dressings  are  to  be  applied,  and  the  whole  secured  as  before 
recommended. 

Another  way  to  avoid  removal  of  the  splint,  when  the  wound-dressing 
is  changed,  is  to  have  a  0 -shaped  arch  formed  on  the  splint,  opposite  the 
wound  (Fig.  88),  so  as  to  render  the  wound  and  its  surroundings  accessible 
all  around.  Such  a  splint  would  need  to  be  reinforced  by  a  strip  of  hoop- 


264 


THE    TREATMENT    OF    WOUNDS. 


iron,  bent  in  the  same  way,  and  inclosed  in  the  plaster.  Such  a  splint 
resembles  much  the  interrupted  circular  splint  (Figs.  76,  79). 

Concave  splints  of  wood,  tin,  or  wire,  applied  over  the  wound-dressing, 
may  be  used  to  advantage  in  many  cases. 

Some  kind  of  suspension-splint,  with  extension  by  means  of  adhesive 
plaster  strips,  a  weight  and  pulley,  affords,  as  a  rule,  the  best  advantages 
for  carrying  out  the  antiseptic  treatment  of  a  wound  complicated  with 
fracture. 

The  fenestrated  or  interrupted  plaster-of-Paris  encircling  splint  may 
be  employed  with  advantage  as  soon  as  the  process  of  healing  has  suffi- 


FIG.  89.— Bowed  Plaster  Splint,  Applied  and  Suspended. 

ciently  advanced  to  exclude  danger  from  sepsis  and  inflammation.  This 
period  may  arrive  within  two  or  three  weeks,  if  the  conditions  are  favor- 
able, but  may  be  delayed  for  a  much  longer  time.  When  the  secretions 
have  nearly  ceased,  the  wound  is  covered  with  granulations,  and  the  inci- 
sions have  either  healed  or  have  become  superficial  granulating  surfaces, 
the  perfect  immobilization  of  the  fracture  assumes  greater  importance 
than  the  rigid  antiseptic  treatment  of  the  external  wound.  No  method  of 
fracture-dressing  can  secure  the  desired  immobility  of  the  bone-fragments, 
and  yet  permit  the  necessary  attentions  to  the  wound,  but  the  encircling 
plaster  splint,  fenestrated  or  interrupted. 


FENESTRATED    PLASTER    SPLINTS.  265 

The  application  of  the  plaster-dressing  in  these  cases  requires  great 
care  and  experience  to  preserve  the  continuation  of  the  antiseptic  treat- 
ment If  the  wound  is  small,  fenestration  of  the  splint  will  suffice ;  if  it 
is  extensive,  or  if  several  wounds  coexist,  it  must  be  interrupted. 

Application  of  the  Fenestrated  Splint. — The  fenestrated  plaster-of-Paris 
splint  is  applied  as  follows  :  The  wound  and  its  immediate  vicinity,  to  the 
extent  of  one  to  two  inches,  are  covered  temporarily  with  a  number  of 
folds  of  antiseptic  gauze  or  cotton,  which  will  afterward  form  a  projection 
in  the  plaster  casing,  by  which  the  location  of  the  fenestrum  will  be 
marked.  As  a  basis  for  the  plaster  dressing,  the  whole  limb,  after  having 
been  well  cleansed  with  an  antiseptic  lotion,  should  be  wrapped  in  anti- 
septic cotton.  The  plaster  bandages  should  then  be  applied  in  the  usual 
way  (Chapter  XL,  p.  211).  The  plaster  bandage  may  be  reinforced  by  the 
insertion  between  its  layers  of  one  or  more  longitudinal  strips  of  sheet-iron. 


FIG.  90.— Lath-gypsum  Splint  of  Pirogoff  (EsmarcA). 

As  soon  as  the  plaster  is  sufficiently  hard,  the  fenestrum  is  made,  and 
the  temporary  antiseptic  dressing  is  removed  through  the  window.  The 
spaces  at  the  margins  of  the  opening  are  filled  thoroughly  with  antiseptic 
paste  (ten  per  cent  carbolized  oil  and  common  chalk  or  whiting).  Finally, 
the  whole  space  within  the  fenestrum  is  filled  with  antiseptic  protective 
material ;  over  all  a  layer  of  impermeable  tissue  is  placed  which  shall 
overlap  the  circumference  of  the  fenestrum  from  two  to  three  inches,  being 
secured  in  place  by  a  gauze  bandage. 

The  limb  should  then  be  suspended. 

If  it  becomes  necessary  for  the  fenestrum  to  be  so  large  that  the  splint 
is  materially  weakened  by  it,  a  wooden  strip  might  be  placed  longitudinally 
over  the  limb,  crossing  the  window,  as  in  the  "  Lath-gypsum  "  dressing  of 
Pirogoff  (Fig.  90).  In  this  dressing  of  Pirogoff,  after  a  strong  plaster-of- 


266 


THE    TREATMENT    OF    WOUNDS. 


Paris  splint  of  coarse  sackcloth,  soaked  in  plaster  cream,  has  been  applied 
to  the  calf,  two  large  balls  of  tow,  saturated  with  the  plaster  cream,  are 
placed  upon  the  anterior  surface  of  the  leg  ;  a  wooden  lath  is  then  fastened 

upon  the  tow  with  broad  strips  of  linen,  which 
are  also  impregnated  with  the  plaster  cream. 

The  interrupted  plaster  dressing  (Chapter 
XL,  p.  212)  is  suitable  in  extensive  injuries  of 
the  soft  parts,  or  in  multiple  incisions  and 
counter-incisions.  The  bridges  (Fig.  91),  pre- 
ferably of  sheet-iron,  which  connect  the  two 
pieces  of  the  dressing  should  extend  along  the 
whole  length  of  the  sections  of  the  dressing 
into  which  they  are  inserted,  and  should  be 
applied  one  externally  and  the  other  internally, 
to  the  limb.  They  should  be  fastened  by  a 
sufficient  number  of  turns  of  plaster  bandage 
to  give  the  apparatus  sufficient  strength.  The 
margins  of  the  dressing  in  the  neighborhood 
of  the  wound  should  be  filled  in  with  the  anti- 
septic paste,  and  the  antiseptic  dressing  ap- 
plied to  the  wound  as  usual 

The  form  of  interrupted  plaster  dressing, 
called  by  Szymanowski  the  honeycomb  plaster 
dressing,  may  be  easily  improvised  and  applied 
in  cases  where  extensive  or  multiple  injuries  ex- 
ist It  consists  of  applying  first  as  many  sepa- 

,  .  _  .     . 

rate  plaster  rings  as  the  required  interruptions 
make  necessary,  and  then  connecting  these  with  narrow  wooden  strips,  which 
are  fastened  to  the  plaster  rings  by  other  turns  of  the  plaster  bandage  until 
the  whole  is  consolidated  with  sufficient  firmness  to  secure  absolute  immo- 
bility to  the  enclosed  parts.  The  interspaces  between  the  wooden  strips  per- 
mit a  thorough  dressing  of  the  wounds  and  frequent  renewal  of  the  same. 

If  either  the  fenestrated  or  interrupted  plaster  dressing,  in  any  form,  is 
used,  it  must  remain  in  place  till  the  wound  is  covered  by  skin.  As  by 
antiseptic  methods  of  treatment  this  will  have  happened  long  before  con- 
solidation of  the  fracture  has  occurred,  a  close  plaster  dressing  should  be 
substituted  for  the  open  one  during  the  period  that  will  yet  remain  before 
firm  union  of  the  bone  is  accomplished. 


Fio.  91.  —  Interrupted  Plaster  Dressing 


PART   II. 


SPECIAL     WOUNDS 


SECTION  II. 

WOUNDS    OF    TISSUES    COMMON    TO    ALL    PARTS    OF 

THE    BODY. 


CHAPTER   XYI. 
WOUNDS  OF  MUSCLES— TENDONS— NERVES. 

Wounds  of  Muscles— Difficulties  of  Coaptation— Position— Bandaging— Suturing^ 
Rest— Protection  from  Sepsis— Subcutaneous  Ruptures — Wounds  of  Tendons — 
Healing  of  Subcutaneous  Wounds — Difficulties  of  Open  Wounds — Importance  of 
Antisepsis,  Protection,  and  Rest — Suturing  Tendons — Lange's  Case — Pauly's 
Case —  Wounds  of  Nerves — Importance  of  Approximation  of  Divided  Ends — Meth- 
ods of  Approximation — Suturing  Nerves — Tollman's  Statistics — Results  reported 
by  Page— Pye's  Case — Page's  Case — Application  of  the  Nerce-sutiire — Direct 
Nerve-suture —Peri-neural  Suture — The  Suture  Material — Conditions  Requiring 
Nerve-suture — Neuroplasty — Tubular  Suture — Centra-indications — Requisites  to 
Success. 

WOUNDS  OF  MUSCLES. 

THE  retractile  nature  of  the  muscular  tissue,  by  its  tendency  to  cause 
wide  separation  of  the  divided  ends  of  an  injured  muscle,  occasions  special 
difficulties  in  the  treatment  of  wounds  of  these  organs.  In  order  to  bring 
the  wound-surfaces  into  apposition  it  is  necessary  that  the  part  be  placed 
in  a  position  of  complete  relaxation,  in  which  it  must  be  kept  during  the 
course  of  the  healing,  till  firm  union  has  taken  place.  When  it  is  a  muscle 
of  one  of  the  extremities  that  is  wounded,  the  continued  relaxation  of 
either  portion  will  be  promoted  by  the  application  of  two  roller  bandages, 
applied  in  opposite  directions,  each  beginning  at  that  part  of  the  muscle 
most  distant  from  the  wound,  and  approaching  the  wound  as  they  are 
applied.  Thus  the  contraction  of  the  fleshy  fibres  may  be  controlled,  and 
the  approximation  of  the  retracted  ends  favored. 

The  permanent  functional  impairment  which  is  entailed  by  a  failure  to 
secure  approximation  and  union  of  the  divided  ends  of  a  muscle,  lends  im- 
portance to  every  means  which  can  be  adopted  which  will  prevent  such 
failure.  Sutures  should  be  applied — sutures  of  relaxation  and  of  coapta- 
tion — the  deeper  sutures  being  carried  through  nearly  the  whole  thickness 


270  THE    TREATMENT    OF    WOUNDS. 

of  the  muscla  Rest  by  means  of  position,  compression,  and  immobiliza- 
tion should  be  maintained  with  great  care.  When  adequate  protection 
against  the  causes  of  inflammation  is  neglected,  approximation  by  sutures 
will  be  of  little  value,  since  the  softening  of  the  tissue,  even  to  some  little 
distance  from  the  surface  of  the  wound,  consequent  upon  the  inflammatory 
changes,  will  cause  them  to  be  easily  torn  out  Every  precaution,  there- 
fore, of  wound-cleanliness  and  of  antiseptic  dressing  should  be  observed  in 
the  care  of  this  class  of  wounds,  to  prevent  the  production  of  inflammatory 
or  septic  disturbances. 

In  the  treatment  of  subcutaneous  ruptures  of  muscles,  when  the  muscle 
is  one  whose  function  is  of  importance,  and  is  so  situated  that  it  is  accessi- 
ble without  endangering  more  important  organs  in  the  operation,  the  pro- 
tection of  the  unbroken  skin  should  be  sacrificed,  and  the  wound  converted 
into  an  open  one,  in  order  that  the  more  important  indication  of  bringing 
the  retracted  ends  into  coaptation  by  sutures  may  be  accomplished. 
Should  the  edges  of  the  wound  across  the  muscle  prove  to  be  ragged,  they 
should  be  trimmed  sufficiently  to  permit  of  close  apposition  of  the  surfaces. 

Subcutaneous  muscular  ruptures  which  are  too  deep  seated,  or  which 
are  complicated  with  other  injuries  that  make  their  exposure  by  incision 
inadvisable,  should  be  treated  in  accordance  with  the  general  methods 
described  for  the  management  of  subcutaneous  injuries. 

WOUNDS  OF  TENDONS. 

Approximation  of  the  divided  ends  of  a  severed  tendon  must  be  favored 
by  placing  the  part  in  that  position  which  will  fully  relax  the  attached 
muscle  ;  appropriate  means  of  immobilization  and  compression  must  then 
be  used  to  prevent  retraction  and  separation  during  the  period  of  repair. 
The  healing  of  subcutaneous  wounds  may  be  expected  to  progress  undis- 
turbed without  other  treatment,  if  these  precautions  be  observed.  Divided 
tendons,  in  which  the  injury  has  been  accompanied  by  a  simple  punctured 
wound  of  the  skin,  as  in  the  operations  of  tenotomy  for  orthopaedic  pur- 
posas,  in  which  immediate  occlusion  of  the  external  wound  is  accompanied 
by  its  healing  by  primary  union,  require  the  same  simple  treatment  as  if 
the  wound  had  been  absolutely  subcutaneous  from  the  first. 

Open  wounds  exposing  divided  tendons  present  conditions  especially 
favorable  for  the  development  of  wound-disturbances,  which  conditions  are 
still  more  aggravated  in  those  cases  in  which  a  synovia!  sheath  for  the  ten- 


WOUNDS    OF   TENDONS.  271 

don  is  likewise  opened.  The  retraction  of  the  tendon-fragments  prevents 
approximation  and  primary  union,  and  leaves  recesses  for  the  accumula- 
tion and  retention  of  secretions  ;  the  synovia!  sheaths  offer  favorable  mate- 
rial and  surfaces  for  the  development  of  sepsis,  and  in  their  absence  the 
connective-tissue  that  ensheaths  the  tendon  affords  a  favorable  tissue  for 
the  development  and  extension  of  phlegmonous  inflammations.  A  strict 
observance  of  every  detail  of  wound-cleanliness  and  disinfection  is  there- 
fore necessaiy  in  the  treatment  of  open  wounds  of  tendons.  Perfect  arrest 
of  haemorrhage  must  be  accomplished.  The  primary  cleansing  of  the 
wound  must  be  scrupulous,  and  adequate  means  for  drainage  must  be 
provided.  The  ends  of  the  divided  tendons  must  be  sought  for,  and  their 
coaptation  effected  and  maintained  by  sutures.  It  is  less 'essential  what 
the  exact  kind  of  suture  it  is  that  is  employed,  than  that  it  be  aseptic  and 
of  sufficient  durability  to  maintain  the  coaptation  till  the  union  shall  be 
firm.  The  suture  should  be  passed  through  the  tendon  sufficiently  far 
from  its  edge  that  it  shall  not  be  easily  torn  out  The  external  wound 
should  then  be  closed,  with  due  attention  to  drainage.  Protective  dress- 
ings and  provisions  for  rest  should  be  applied  with  minute  care. 

The  treatment  of  wounds  involving  tendons,  in  which  suppuration  or 
inflammatory  disturbances  have  already  declared  themselves  must  be  con- 
ducted in  accordance  with  the  methods  governing  the  treatment  of  such 
wounds  in  general.  The  suture  of  the  tendon-fragments  will  have  to  be 
abandoned  or  omitted  in  such  cases,  and  their  direct  union  left  to  be 
accomplished  by  operative  measures  at  a  later  period,  after  cicatrization 
of  the  wound  has  been  effected. 

When  marked  impairment  of  function  remains  long  after  the  wound 
has  healed,  as  the  result  of  a  gap  which  persists  between  the  retracted 
ends  of  a  divided  tendon,  whether  the  original  injury  have  been  a  subcu- 
taneous rupture  or  an  open  wound,  the  parts  should  be  exposed  by  a  free 
incision,  the  ends  of  the  tendon-fragments  freed  from  any  new  attach- 
ments, freshened,  and,  having  been  brought,  if  possible,  into  coaptation, 
sutured  together.  If  the  end  of  the  proximal  fragment  cannot  be  found, 
or  cannot  be  brought  down  to  the  distal  fragment,  the  freshened  end  of 
the  latter  may  be  attached  to  a  contiguous  tendon,  with  the  result  of  res- 
toration of  some  power  over  the  supplied  part  If  the  matting  of  the  end 
of  the  distal  fragment  in  the  cicatricial  tissue  at  the  point  of  injury  is  so 
extensive  as  to  make  its  isolation  unwise,  the  end  of  the  proximal  frag- 
ment may  be  brought  down  and  likewise  attached  to  the  cicatrix,  with  the 


272  THE    TREATMENT    OF    WOUNDS. 

result  of  increasing  the  amount  of  voluntary  control  over  the  parts  beyond. 
As  an  example  of  the  results  which  may  be  obtained  from  exposure  and 
suture  of  divided  tendons  subsequent  to  the  healing  of  the  primary  wound, 
the  following  case  may  be  quoted  :  At  the  meeting  of  the  New  York  Sur- 
gical Society  of  March  13,  1883,  Dr.  F.  Lange  presented  a  lady  patient 
who,  about  two  months  previously,  had  fallen  from  a  considerable  height, 
and  sustained  a  wound,  cutting  the  tendons  of  the  extensor  muscles  of  the 
left  forearm.  He  saw  the  patient  two  weeks  afterward,  when  the  wound 
was  almost  healed,  and  there  was  extensor  paralysis  involving  the  third 
and  fourth  fingers,  only  the  last  two  joints  moving  through  the  action  of 
the  interossei.  About  two  weeks  later  Dr.  Lange  made  a  longitudinal  in- 
cision, and  found  that  three  of  the  extensor  tendons  had  been  divided, 
namely,  those  belonging  to  the  third  and  fourth  fingers,  and  to  the  index 
finger.  The  extensor  indicis  proprius  was  not  injured,  for  the  action  of 
the  index  existed.  The  divided  tendons  of  the  extensors  were  separated 
to  a  distance  of  almost  one  inch  and  a  half.  They  were  brought  together 
and  sutured  with  antiseptic  silk.  The  hand  was  then  put  in  a  position  of 
superextension,  and  an  antiseptic  dressing  applied.  The  sutures  were  re- 
moved at  the  end  of  one  week.  The  result  was  that  the  movements  of  the 
fingers  could  already  be  quite  satisfactorily  performed,  and  it  was  probable 
that  improvement  would  still  continue. 

The  results  of  the  immediate  suture  of  a  divided  tendon,  with  proper 
after-treatment,  are  exemplified  in  the  following  case,  reported  by  Pauly, ' 
of  Posen.  It  is  also  quoted  by  MacCormac,  in  his  Antiseptic  Surgery. 

A  boy  fell  from  the  top  of  a  hay  wagon,  with  the  left  heel  right  across 
the  blade  of  a  scythe. 

A  wound  four  inches  long,  extended  transversely  from  one  malleolus  to 
the  other,  completely  dividing  the  tendo  Achillis,  and  opening  the  ankle- 
joint  from  behind.  The  tuberosity  of  the  os  calcis,  with  the  piece  of 
tendo  Achillis  attached  to  it,  about  an  inch  in  length,  was  completely  sev- 
ered from  the  rest  of  the  bone,  to  which  it  remained  connected  by  soft 
parts  alone.  Antiseptic  treatment  was  adopted.  The  detached  tuberosity 
was  fastened  in  its  place  by  a  common  nail,  and  while  the  foot  was  main- 
tained in  the  equinus. position,  the  divided  surfaces  of  the  Achilles  tendon 
were  united  together  by  catgut  sutures  inserted  alternately  deeply  and 
superficially  into  the  substance  of  the  tendon. 

1  Centralbtatt  fur  Chiritrgie,  January,  1878. 


WOUNDS    OF   NERVES.  273 

In  nineteen  days  a  complete  recovery  was  accomplished,  and  one  year 
afterward,  the  report  states  that  the  function  of  the  limb  was  perfectly 
normal 

WOUNDS  OF  NERVES. 

While  it  is  true  that,  in  general,  wounds  of  nerves  should  be  treated  on 
the  same  general  principles  as  wounds  of  other  structures,  yet  special  at- 
tention is  demanded  to  the  methods  and  results  of  attempts  at  securing 
approximation  of  the  divided  ends  in  those  cases  in  which  important  nerve- 
trunks  are  severed. 

The  regeneration  of  nerve-tissue  through  a  cicatrix,  and  thus  the 
spontaneous  restoration  of  the  function  of  a  nerve  that  has  been  divided, 
even  when  considerable  loss  of  substance,  or  retraction  from  each  other  of 
the  divided  ends  has  been  present,  has  been  observed  to  occur  with  suffi- 
cient frequency  to  render  not  altogether  hopeless  any  recent  case  of  paraly- 
sis resulting  from  section  of  a  nerve  ;  as  a  rule,  however,  the  re-establish- 
ment of  the  functions  of  a  nerve  never  takes  place  when  its  extremities 
have  been  allowed  to  become  separately  cicatrized ;  but  in  such  cases  an 
after-history  of  abolished  function,  neuralgic  and  trophic  disturbances  »is 
entailed.  When,  however,  the  ends  of  the  divided  nerve  can  be  brought 
into  early  apposition,  and  primary  union  of  the  wound  can  be  secured, 
speedy  restoration  of  function  in  great  part  may  be  confidently  counted 
upon. 

The  indication  is  imperative,  therefore,  to  secure  and  maintain  the 
closest  possible  approximation  of  the  cut  surfaces  of  a  divided  nerve  dur- 
ing the  healing  of  the  wound,  that  the  amount  of  cicatricial  tissue  may  be 
reduced  to  a  minimum,  and  that  the  more  speedy  and  certain  restoration 
of  function  may  be  favored. 

A  degree  of  approximation  may  be  secured  by  the  position  of  the 
wounded  part,  by  keeping  it  in  such  a  position  that  the  nerve-trunk  shall 
be  relaxed,  and  by  those  means  of  approximation  which  may  be  applied  to 
secure  coaptation  of  the  surfaces  of  the  wound  in  general ;  but  the  intrinsic 
retraction  of  the  fragments  of  the  nerve-trunk  itself  will  still  cause,  in  most 
instances,  more  or  less  of  a  gap  to  remain  between  them. 

In  contused  and  lacerated  wounds,  and  in  wounds  in  which  there  is 
appreciable  loss  of  substance,  it  is  unlikely  that  even  approximate  apposi- 
tion of  the  ends  of  divided  nerves  could  be  effected  without  the  use  of 

special  means.     The  natural  resource  in  such  cases,  in  addition  to  the  gen- 
18 


274  THE    TREATMENT    OF    WOUNDS. 

eral  means  of  relaxation  and  approximation  already  referred  to,  would  be 
to  isolate  the  separated  ends  of  the  nerve-fragments,  draw  them  down  into 

apposition  with  each  other,  and  keep  them  apposed  by  suturing  them  to- 

^ 
gether. 

The  knowledge  of  the  evil  effects  frequently  due  to  punctures  of  nerves 
and  to  their  inclusion  in  ligatures,  the  fear  of  tetanus  and  of  inflammatory 
complications,  has,  however,  rendered  surgeons  cautious  in  resorting  to 
nerve-suture.  A  more  frequent  resort  to  it  has,  however,  marked  the  prac- 
tice of  surgeons  of  late  years ;  in  none  of  the  reported  cases  have  untoward 
complications  occurred,  and  the  marked  benefits  secured  by  its  practice 
have  now  established  it  as  a  regular  surgical  procedure,  the  neglect  of 
which,  in  the  cases  calling  for  it,  would  be  censurable. 

In  a  paper  devoted  to  the  subject  of  wounds  and  suture  of  nerves,  by 
Tillmans, l  of  Leipsic,  in  1881,  out  of  42  cases  of  nerve-suture,  in  general, 
which  he  tabulates,  in  22  cases  the  appli cation  of  the  primary  suture  is 
stated  to  have  been  made.  In  13  of  these  the  result,  as  regards  restoration 
of  function,  is  stated  to  have  been  successful ;  in  one,  only,  unsuccessful ; 
the  remaining  eight  being  classed  as  questionable.  In  eight  other  instances 
sufficient  data  for  determining  whether  the  suture  was  primary  or  not,  is 
not  given.  Four  of  these  resulted  successfully,  one  unsuccessfully,  and 
three  were  questionable.  In  12  instances  at  various  lengths  of  time  after 
cicatrization  of  the  wound  had  taken  place,  the  separated  nerve-ends  were 
exposed  by  proper  incisions,  and  their  refreshed  ends,  having  been  brought 
together,  were  sutured.  Of  these  cases  of  secondary  suture,  six  resulted 
successfully  and  six  are  classed  as  questionable.  Herbert  "W.  Page,2  of 
London,  has  related  four  successful  cases  of  primary  suture  not  included  in 
Tilhnans'  tables,  two  from  the  practice  of  Mr.  Favell,  one  from  Mr.  Pye, 
and  one  case  of  his  own.  More  recently  Mr.  Page  has  reported 3  the  ulti- 
mate results  of  two  cases  of  secondary  suture,  one  having  been  completely 
successful,  the  other  but  partially  so. 

The  case  of  primary  suture  of  Mr.  Pye,  and  that  of  secondary  suture  of 
Mr.  Page  may  be  detailed  as  fair  examples  of  the  two  classes  of  procedure. 
In  the  first  instance,  a  lad,  aged  14,  caught  his  arm  in  a  printing-machine 

1  Ueber  Nervenverletzungen  und  Nervennaht.  Archiv  fur  KliniscJie  Chirurgie, 
xvii.  1. 

*  The  Immediate  Suture  of  Divided  Nerves.  British  Medical  Journal,  May  7, 
1881,  p.  717. 

3  Case  of  Secondary  Suture  of  Ulnar  Nerve  Six  Months  after  its  Division.  British 
Medical  Journal,  June  23,  1883,  p.  1223. 


NEEVE-SUTURE.  275 

and  received  a  lacerated  wound  behind  and  on  either  side  of  the  left  elbow- 
joint,  exposing  the  internal  and  anterior  aspects  of  the  capsule  of  the  joint 
with  the  brachial  artery,  tearing  the  tendon  of  the  triceps,  and  chipping  off 
part  of  the  internal  condyle  of  the  humerus.  The  median  nerve  was  torn 
completely  across.  The  ends  of  the  nerve  were  brought  together,  as  nearly 
as  possible,  by  catgut  sutures  passed  through  the  substance  of  the  nerve 
and  through  its  sheath.  The  wound  was  lightly  dressed  with  carbolic  acid, 
and  the  arm  was  placed  in  an  angular  splint.  During  the  first  week  there- 
after the  motor  and  sensory  paralysis  appeared  complete  in  the  hand  and 
in  the  muscles  of  the  forearm  supplied  by  the  nerve.  Then  there  began 
some  pricking  and  tingling  of  the  forefinger,  soon  followed  by  commencing 
power  of  flexion.  The  return  of  sensation,  once  started,  progressed  rapidly 
and  was  nearly  complete  by  the  end  of  the  month.  The  ball  of  the  thumb 
and  the  radial  side  of  the  middle  finger  remained  insensitive  throughout. 
The  return  of  muscular  power  was  fairly  good,  but  was  more  difficult  to 
estimate  in  consequence  of  the  cicatrization  of  the  wound. 

The  example  of  secondary  suture  which  I  desire  to  quote  was  the  case 
of  a  man,  aged  25,  who  six  months  previously  had  received  a  severe  wound 
of  the  left  wrist  from  glass,  which  was  a  month  in  healing.  From  that 
time  he  had  extreme  pain  in  the  cicatrix,  his  ring  and  little  fingers  became 
bent  and  useless,  and  he  was  obliged  to  cany  his  arm  in  a  sling.  When 
admitted  for  treatment,  the  wound  cicatrix  was  excessively  tender,  he  had 
lost  the  power  of  extending  the  two  last  phalanges  of  the  ring  and  little 
fingers,  and,  to  a  less  extent,  of  the  other  fingers  also,  and  the  thenar  and 
hypothenar  eminences,  together  with  the  interossei,  were  markedly  wasted. 
Sensation  was  very  defective,  though  not  entirely  absent,  in  the  ring  and 
little  fingers,  more  especially  on  their  palmar  surfaces.  The  whole  hand, 
indeed,  was  somewhat  anaesthetic  and  withered  from  disease.  It  sweated 
constantly  and  profusely ;  the  little  finger  was  blue  and  slightly  swollen, 
and  the  nail  was  much  misshapen. 

April  4,  1881,  Mr.  Page  cut  down  on  the  site  of  the  ulnar  nerve,  and 
with  much  difficulty  found  the  separated  ends.  The  upper  end  of  the 
lower  portion  was  found  turned  downward  and  inward,  and  ended  in 
thick  cicatricial  tissue  on  the  under  surface  of  the  tendon  of  the  flexor 
carpi  ulnaris.  It  was  not  enlarged,  and  a  transverse  section  of  it,  when 
freed  from  the  cicatrix,  showed  the  appearances  of  healthy  nerve.  The 
lower  end  of  the  upper  portion  was  swollen  to  about  three  times  its  natural 
size,  and  ended  in  a  firm  bulbous  nodule,  which  also  was  bound  in  cica- 


276  THE   TREATMENT    OF   WOUNDS. 

tricial  tissue.  From  this  it  was  dissected,  and  a  third  of  an  inch  had  to  be 
removed  before  the  section  looked  natural  It  was  necessary  to  dissect  the 
upper  part  of  the  nerve  free  for  a  couple  of  inches,  before  the  two  ends 
could  be  brought  into  comfortable  apposition  ;  they  were  then  joined  by 
three  fine  catgut  sutures  passed  through  both  sheath  and  nerve.  The 
wound  healed  by  first  intention.  As  early  as  the  tenth  day  the  anaesthesia 
was  less  marked.  At  the  end  of  three  weeks,  sensation  had  decidedly  im- 
proved, the  cicatrix  was  free  from  pain,  and  some  return  of  the  power  of 
extension  of  the  last  phalanges  of  the  ring  and  little  fingers  was  evident.  At 
the  end  of  twenty-two  months,  during  the  first  year  of  which  appropriate 
galvanic  and  faradic  treatment  had  been  persevered  in,  his  hand  was  as 
useful  as  it  had  ever  been.  There  was  no  sign  of  trophic  disturbance  ; 
sensation  was  normal;  there  was  no  wasting;  he,  however,  experienced 
occasional  pain  in  the  cicatrix  on  change  of  weather,  and  was  unable  to 
perfectly  extend  the  last  phalanx  of  the  little  finger. 

APPLICATION  OF  THE  NEKVE-SUTUBE. — For  the  purpose  of  securing  apposi- 
tion of  the  two  ends  of  a  cut  nerve,  sutures  may  be  introduced  either 
through  the  substance  of  the  nerve-trunk  itself  or  simply  through  the  con- 
nective-tissue that  acts  as  a  sheath  to  the  nerve,  including,  perhaps,  the 
neurilemma.  The  former  constitutes  "direct  nerve-suture,"  the  latter  "in- 
direct" or  "peri-neural"  suture. 

Direct  Nerve-suture. — This  is  the  form  of  suture  which  has  been  re- 
sorted to  in  the  greater  number  of  the  published  cases  of  nerve-suture. 
By  means  of  a  fine  needle  the  thread  is  made  to  traverse  the  body  of  the 
nerve  and  embrace  its  substance  in  the  knot  which  is  tied.  By  some  the 
nerve  has  been  pierced  through  and  through ;  others  have  brought  out  the 
thread  at  the  lower,  or  at  the  middle  part  of  the  cut  surface.  The  latter 
method  is  more  likely  to  secure  accurate  and  steady  coaptation,  but  if  there 
is  any  strain  upon  the  suture,  it  will  be  more  quickly  cut  out  In  the 
former  method  greater  care  will  be  required  to  obtain  exact  adjustment 
and  avoid  angular  deviation  of  the  ends  when  the  knot  is  tied,  but  it  gives  a 
greater  security  against  subsequent  gaping  by  retraction.  One  thread  only 
will  suffice,  unless  a  large  trunk,  as  the  great  sciatic,  is  under  treatment. 

Peri-neural  Suture — The  insertion  of  the  sutures  through  the  peri-neu- 
ral connective-tissue,  when,  by  so  doing,  sufficient  traction  on  the  nerve- 
fragments  can  be  effected  to  overcome  the  gaping  at  the  point  of  divi- 
sion, recommends  itself  by  the  fact  that  by  its  practice  the  nerve-bundles 
neither  receive  injury  by  the  needle  puncture  nor  by  the  after-strain  of 


THE    NERVE-SUTURE.  277 

the  thread.  For  its  application  two  sutures  are  required,  one  at  either 
side  of,  and  close  to,  the  nerve.  When  the  sutures  are  drawn  up  and  care- 
fully knotted,  coaptation  of  the  cut  surfaces  of  the  nerve  may  be  obtained 
with  even  more  accuracy  than  when  the  direct  suture  is  employed.  The 
results  obtained  by  the  use  of  the  indirect  suture  have  been  very  satisfac- 
tory. In  seven  of  the  cases  reported  by  Tilhnans,  was  this  method  of 
coaptation  used,  with  a  successful  result  in  all  but  one. 

Both  the  direct  and  the  indirect  methods  may  be  employed  in  the 
same  case,  when  the  conditions  seem  to  require  it,  the  one  great  indication 
to  be  met  being  exact  and  stable  coaptation  of  the  cut  surfaces. 

TJie  Suture  Material. — The  choice  of  the  thread  for  the  suture  is  of  im- 
portance, for  the  highest  success  of  the  suture  can  be  obtained  only  by 
securing  union  by  first  intention.  No  material  should  be  used  for  the 
suture  which  will  interfere  with  primary  union  of  the  wound.  Aseptic 
catgut,  silk,  or  silver  wire  may  be  used,  but  the  catgut  is  to  be  preferred, 
as  by  its  subsequent  spontaneous  absorption  it  is  not  so  likely  to  become  a 
source  of  future  irritation.  By  the  use  of  catgut,  and  the  indirect  method 
of  suture,  no  hesitancy  need  be  felt  in  the  application  of  the  suture  in 
every  case  of  complete  division  of  a  nerve-trunk. 

CONDITIONS  REQUIKINO  NERVE-SUTURE. — A  recent  wound,  in  which  a 
nerve-trunk  has  been  severed,  requires  the  separate  suturing  of  the  ends 
of  the  divided  nerve,  as  one  of  the  elements  of  securing  proper  "  wound- 
apposition."  Some  latitude  of  practice  and  judgment  may  be  allowed  in 
cases  in  which  the  external  wound  is  quite  restricted,  and  in  which  little 
tendency  to  retraction  may  be  supposed  to  exist,  and  by  position  and  the 
general  measures  instituted  for  the  approximation  of  the  wound-surfaces, 
its  primary  union  is  probable. 

When  the  external  wound  is  considerable,  even  though  the  retraction 
of  the  divided  ends  of  the  nerve  is  not  great,  the  suture  should  be  em- 
ployed. 

When  decided  separation  of  the  divided  ends  of  the  nerve  exists,  either 
as  the  result  of  retraction  or  of  loss  of  substance,  the  suture  must  not  be 
omitted.  The  amount  of  separation  which  can  be  overcome,  so  that  the 
ends  of  the  nerve-fragments  can  be  again  apposed,  may  be  considerable. 

Nelaton  brought  together  the  ends  of  the  median  nerve  after  having 
exsected  two  and  one-third  inches  of  its  continuity  ;  von  Langenbeck  ob- 
tained union  between  fragments  of  the  great  sciatic  nerve  that  had  been 
separated  by  a  distance  of  two  inches.  If,  however,  it  is  found  impossible 


278  THE    TREATMENT   OF    WOUNDS. 

to  bring  the  divided  ends  together,  one  of  four  expedients  may  be  adopted. 
First,  if  several  nerves  have  been  divided,  the  expedient  of  Flourens  may 
possibly  be  resorted  to,  that  of  uniting  the  lower  end  of  the  most  impor- 
tant nerve  to  the  upper  end  of  another.  Second,  if  such  less  important 
nerve  be  not  already  divided,  if  it  be  accessible,  a  sufficient  portion  of  its 
surface  may  be  freshened,  and  the  lower  end  of  the  divided  nerve  sutured 
thereto,  virtually  grafting  it  in.  A  successful  instance  of  this  kind  is  re- 
ported by  Marchand,1  from  the  clinic  of  Depres.  A  lacerated  wound  of 
the  left  arm  had  torn  the  median  nerve.  Depres  found  it  impossible  to 
bring  the  central  end  of  the  torn  nerve  down  so  as  to  suture  it  to  its  corre- 
sponding fragment.  He  therefore  exposed  the  ulnar  nerve,  and  having 
separated  its  fibres  by  tearing  them  apart  with  a  pair  of  dressing  forceps, 
into  the  interspaces  inserted  the  fibres  of  the  peripheral  end  of  the  median 
nerve.  The  procedure  was  crowned  with  success,  and  the  patient  recov- 
ered a  useful  hand. 

The  two  remaining  expedients  are  those  of  "neuroplasty,"  or  transplan- 
tation of  nerve-tissue  to  fill  the  gap,  and  of  "  tubular  suture."  These  are 
still  matters  of  physiological  experiment,  but  deserve  mention  in  this  con- 
nection. They  are  referred  to  by  Nicaise,"  as  follows :  "  Gluck,  of  Berlin, 
has  resected  in  chickens  three  or  four  centimetres  (1  to  1£  inch)  of  the 
sciatic  nerve,  which  he  has  replaced  by  a  piece  of  the  sciatic  nerve  of  a 
rabbit,  sutured  at  both  of  its  extremities.  The  chickens  thus  operated 
upon  walked  as  well  as  those  upon  which  direct  suture  of  the  sciatic  had 
been  practised,  while  section  of  the  sciatic  without  suture  or  autoplasty 
produced  a  paralysis  of  this  nerve  which  was  still  complete  at  the  end  of 
ten  weeks.  This  procedure  is  yet  in  the  domain  of  physiology.  "When 
the  separation  of  the  ends  of  the  nerve  is  considerable,  and  they  cannot  be 
brought  in  contact,  the  tubular  suture  of  Gluck  and  Vaulair  may  be  tried. 
The  aim  of  this  is  to  prevent  the  obliteration  of  the  space  which  sepa- 
rates the  two  segments  by  the  interposition  of  a  Neuber's  osseine  tube. 
Gluck  has  only  obtained  negative  results,  but  Vaulair  has  seen,  he  says, 
after  a  delay  of  four  months,  the  regeneration  of  a  nerve-trunk  measuring 
five  centimetres  (2  inches).  He  has  determined  that  the  regeneration  is 
effected  by  centrifugal  granulations  arising  from  the  central  end,  as  has 

1  Gazette  Hebdomadaire  de  Medetine  et  de  Cliirurgie,  1876,  No.  5. 
s  Injuries  and  Diseases  of  Nerves.    International  Encyclopaedia  of  Surgery,  vol. 
KL.  p.  624. 


THE   NERVE-SUTURE.  279 

likewise  been  shown  by  Eichhorst,  Kanvier,  and  Hahn.  He  adds  that  a 
small  portion  only  of  the  new  fibres  unite  with  the  degenerated  fibres  of 
the  peripheral  end." 

When  the  section  of  the  nerve  is  the  result  of  a  contused  wound,  the 
disintegrated  or  badly  contused  portions  of  the  exposed  ends  should  be 
resected  until  surfaces  capable  of  primary  adhesion  are  reached,  which  are 
then  to  be  brought  together.  In  cases  of  severe  contusion  of  a  nerve- 
trunk,  without  actual  solution  of  its  continuity,  the  propriety  of  exsecting 
the  contused  portion  and  suturing  the  extremities  which  remain,  is  worthy 
of  consideration  in  view  of  the  frequent,  prolonged,  and  severe  loss  or  dis- 
turbance of  function  following  nerve-contusions,  and  the  good  results  ob- 
tained by  nerve-suture. 

The  suture  is  contra-indicated  when  the  wound  is  no  longer  recent, 
but  has  begun  to  suppurate.  In  such  cases,  general  measures  of  approxi- 
mation must  alone  be  relied  on  until  cicatrization  has  taken  place,  after 
which,  if  necessary,  operation  for  secondary  suture  may  be  instituted. 

The  approximation  and  suturing  together  of  the  divided  ends  of  a 
nerve  should  be  done  as  early  as  possible  after  the  wound  has  been  in- 
flicted. It  is  important  that  primary  union  be  secured;  minute  observ- 
ance of  every  requirement  of  wound-treatment  should  mark  the  care  of  a 
wound  involving  a  nerve-trunk. 


CHAPTER  XVII. 
WOUNDS  OF  BLOOD-VESSELS. 

Importance  of  Wounds  of  Blood-vessels — Results  to  be  Secured  in  Treatment — Diffi- 
culties—Obliteration of  Vessels— Relations  of  Coagulum  to  Repair — Physiology 
of  Repair — Apposition  of  Inner  Serous  Surfaces — Means  of  Compression — The 
Ligature — Ligation — Gross  or  Immoderate  Violence  in  Tying  a  Ligature — Rules 
of  Procedure —  Complications  of  Wounds  of  Blood-vessels — Primary  Haemorrhage — 
Intermediary  Haemorrhage — Secondary  Haemorrhage — Diffuse  Traumatic  Aneu- 
rism—  Wounds  of  Veins — Peculiarities — Phlebitis  and  Periphlebitis — Thrombosis — 
Effects  of  Septic  Ligatures — Acupressure  and  Forcipressure— J.  E.  Pilcher's  Case 
— Advantages  of  Aseptic  Ligatures — Repair  of  Vein  Wounds— Gross'  Case — 
Langenbeck's  Case — Lateral  Ligation — Braun's  Statistics — Necessary  Precau- 
tions— Lateral  Suture. 

ALL  wounds  involve  wounds  of  blood-vessels,  and  the  indications  for  treat- 
ment which  the  resulting  haemorrhage  presents  have  claimed  attention  in 
connection  with  each  of  the  general  classes  of  wounds  that  have  been  con- 
sidered. There  remain,  however,  certain  special  considerations  with  regard 
to  wounds  of  these  organs  to  which  further  examination  should  be 
directed. 

It  is  impossible  to  exaggerate  the  importance  of  wounds  of  blood- 
vessels ;  the  treatment  which  is  demanded,  when  vessels  of  any  size  are 
involved,  must  be  instantaneously  applied,  in  default  of  which  quick  death 
is  inevitable.  It  is  the  opinion  of  Lidell '  that  more  lives  are  lost  from  the 
haemorrhage  resulting  from  wounds  of  blood-vessels,  either  directly  or  in- 
directly, than  from  all  the  other  consequences  combined  which  flow  from 
wounds.  In  support  of  thia  assertion  he  states  that  of  the  slain  in  battle, 
of  whom  he  had  personal  observation  during  our  "War  of  the  Bebellion,  a 
very  large  share,  about  one-half,  possibly  even  more  than  that,  perished  by 
haemorrhage  from  wounds  of  the  large  blood-vessels  of  the  neck,  chest, 
abdomen,  groin,  etc.,  or  from  wounds  involving  vital  organs  like  the  brain 

1  Injuries  of  Blood-vessels.     International  Encyclopaedia  of  Surgery,  vol.  iii.,  p.  46. 


WOUNDS    OF   BLOOD-VESSELS.  281 

and  lungs,  the  bleeding  whereof  caused  deadly  compression  of  these 
organs  before  succor  could  be  afforded. 

The  treatment,  again,  must  be  effectual  for  the  permanent  obliteration 
of  the  open  orifices  in  the  wounded  vessel,  otherwise  renewed  peril  from 
the  escape  of  blood  will  supervene. 

The  treatment  of  the  wounded  vessel  should,  if  possible,  be  conducted 
in  such  a  way  as  to  avoid  introducing  sources  of  disturbance  into  the  heal- 
ing of  the  other  wounded  tissues  ;  thereby,  also,  its  own  undisturbed  repair 
will  the  most  certainly  be  secured.  The  elements  of  treatment  which 
wounded  blood-vessels  require  do  not  differ  from  those  required  by  other 
tissues.  Haemorrhage  must  be  arrested,  the  wound  must  be  cleansed  and 
brought  into  apposition,  protection  against  disturbance  from  without  must 
be  supplied,  and  rest  must  be  secured  until  repair  is  perfected. 

The  practical  difficulties  which  compl\cai£  the  treatment  of  these 
wounds  spring  from  the  peculiar  function  and  anatomical  character  of  the 
organ.  The  blood-pressure  within  them  is  a  constant  force  tending  to 
separate  the  edges  of  the  wound,  while  the  escape  of  this  vital  fluid  con- 
stitutes a  danger  which  must  be  prevented  at  the  sacrifice,  if  necessary,  of 
the  functional  activity  of  the  organ  itself.  The  thin  walls  of  the  organ  do 
not  afford  sufficient  surface,  when  wounded,  for  securing  perfect  and 
reliable  apposition  of  the  edges  of  the  wound,  in  antagonism  to  the  press- 
ure of  the  column  of  blood  which  they  enclose,  and  to  the  intrinsic  ten- 
dency to  gaping  from  the  contractility  of  its  own  tissue.  Longitudinal 
wounds  of  veins,  however,  in  many  instances  form  an  exception  to  this 
statement  The  readiness  with  which  the  internal  tunic  of  blood-vessels 
responds  to  irritation  by  the  production  upon  its  surface  of  plastic 
material,  suffices,  when  taken  advantage  of,  to  supplement  the  reparative 
deficiencies  of  the  cut  surfaces.  From  this  source  granulation  tissue  is 
produced  that  by  its  organization  obliterates  that  part  of  the  vessel  filled 
by  it,  and  permits  the  undisturbed  organization  of  the  reparative  material 
produced  from  the  wound-surfaces  themselves.  The  coagulum  which 
forms  within  the  last  portion  of  the  canal  of  a  severed  vessel,  and  blocks  it 
up,  not  only  serves  as  a  temporary  plug  to  prevent  the  escape  of  blood,  but 
it  stimulates  the  vascular  tunic,  with  which  it  is  in  contact,  to  an  increased 
cell-activity  that  results  in  new  tissue  that  not  only  assists  in  forming  a 
permanent  seal  to  the  vessel,  but  also  invading  the  clot,  substitutes  for  it 
cicatricial  tissue  that  converts  the  now  unused  portion  of  the  vessel  into  a 
fibrous  cord.  The  result  is  a  total  loss  to  the  economy  of  a  portion  of  its 


282  THE   TREATMENT   OF   WOUNDS. 

substance,  and  the  permanent  impairment  of  function  of  an  organ.  The 
importance  of  this  loss  and  impairment  will  depend  upon  the  importance 
of  the  particular  vessel  and  upon  the  ability  of  other  vessels  to  supplement 
the  defects  of  the  injured  one  by  increased  development  and  labor.  Per- 
manent impairment  of  function,  oadema,  and  gangrene  are  not  infrequent 
results  of  the  obliteration  of  vascular  trunks. 

The  presence  of  a  coagulum,  however,  is  not  essential  to  the  inaugura- 
tion of  the  processes  by  which  a.  wounded  vessel  is  to  be  sealed  up,  and  its 
presence  is  an  embarrassment,  rather,  to  the  repair  when  the  needful  sup- 
port and  rest  to  the  part  can  be  secured  while  its  repair  is  in  progress. 
The  effects  of  the  original  traumatism  by  which  the  vessel  has  been 
wounded  suffice  to  stimulate  that  portion  of  the  internal  tunic  adjacent  to 
the  wound  to  the  needed  nutritive  activity,  and  if  the  effort  of  the  surgeon 
is  successful  in  keeping  the  proliferating  surfaces  of  this  tunic  in  contact 
until  firm  adhesion  has  taken  place  by  the  organization  of  the  new  material 
supplied  by  it,  the  best  result  will  be  obtained. 

Apposition  of  the  wound-surfaces,  therefore,  in  the  case  of  wounds  of 
the  blood-vessels,  with  exceptions  that  will  be  mentioned,  should  be  sub- 
stituted by  apposition  of  the  surfaces  of  that  part  of  the  inner  tunic  of  the 
vessels  which  is  immediately  adjacent  to  the  wound. 

The  treatment  of  wounded  blood-vessels  in  this  respect  involves  the 
same  principles  as  those  which  hereafter  will  be  found  to  govern  the  treat- 
ment of  wounds  of  thin-walled  membranous  organs,  as  the  pericardium, 
alimentary  canal,  or  urinary  bladder,  the  walls  of  which  present  on  one 
side  a  serous  surface,  the  apposition  of  which,  rather  than  of  the  wound 
edges  themselves,  affords  the  most  rapid  and  secure  means  of  closing  a 
penetrating  wound  of  their  substance. 

Some  means  of  compression  will  be  required  in  every  case  for  keeping 
the  inner  surfaces  of  the  vessel  in  contact  until  firm  adhesion,  adhesion 
firm  enough  to  resist  the  impulse  of  the  blood-current,  and  the  tendency 
to  gape  of  the  walls  of  the  vessel  itself,  has  taken  place.  This  will  be 
afforded  by  the  means  which  have  at  once  been  adopted  for  restraining  the 
escape  of  blood.  The  various  resources  which  are  at  the  command  of  the 
surgeon  for  this  purpose  have  already  been  considered  at  length  in  the 
chapter  devoted  to  arrest  of  haemorrhage  (Chapter  VI).  Whatever 
method,  however,  may  have  necessarily  been  adopted  in  the  emergen- 
cy of  the  primary  haemorrhage,  if  the  wounded  vessel  prove  to  be  of  a 
size  that  its  prolonged  compression  is  necessary,  it  should  be  substituted, 


WOUNDS    OF   BLOOD-VESSELS.  283 

at  the  earliest  practicable  moment,  by  the  application  of  an  aseptic 
ligature. 

The  ligature  discharges  two  functions,  that  of  a  means  of  hsemostasis 
and  of  apposition.  In  its  application  for  the  first  purpose,  it  is  essential 
that  it  should  be  drawn  with  such  tightness  that  its  grasp  of  the  vessel 
shall  be  so  firm  that  it  shall  not  slip  off  accidentally.  It  is  not  necessary, 
however,  that  it  should  rupture  any  of  the  coats  of  the  vessel,  or  that  the 
distal  portion  of  the  vessel  should  be  strangulated. 

The  purposes  of  apposition  require  a  force  of  ligation  no  more  power- 
ful than  the  preceding.  The  additional  traumatism  of  ruptured  coats  is 
not  required  for  exciting  or  reinforcing  the  reparative  effort,  while  such 
application  of  a  ligature  as  shall  determine  a  process  of  ulcerative  inflam- 
mation in  the  tissues  grasped  by  it,  is  to  be  deprecated  as  the  possible  de- 
termining cause  of  secondary  haemorrhage. 

In  this  connection  I  cannot  refrain  from  repeating  the  following  ex- 
clamation of  Gross  : l  "  Nothing  is  more  unseemly,  or  more  truly  reprehen- 
sible, in  a  surgeon  or  his  assistant,  than  to  pull  a  ligature  by  fits  and  jerks, 
or  so  violently  as  to  break  it,  or,  perhaps,  lacerate  and  tear  off  the  artery 
itself.  With  a  little  care  and  gentleness,  a  comparatively  weak  ligature 
may  be  thrown  around  a  vessel  so  as  to  answer  the  intention  most  fully. 
I  dwell  upon  this  point  with  some  degree  of  emphasis,  because  it  has  hap- 
pened to  me  to  witness  a  very  unusual  number  of  these  Herculean  feats 
with  the  ligature,  the  men  often  pulling  as  if  they  had  hold  of  a  rope  and 
piece  of  wood,  instead  of  a  delicate  thread  and  artery. 

It  is  important,  as  the  first  step  in  the  treatment  of  a  wounded  blood- 
vessel— it  being  understood  that  in  all  cases  vessels  whose  size  or  relations 
are  such  as  to  require  special  treatment  are  being  referred  to — that  full 
exposure  of  the  wound  in  the  vessel  is  secured.  In  the  case  of  superficial 
wounds,  and  of  deeper  wounds  with  extensive  division  of  the  more  super- 
ficial structures,  such  exposure  of  a  wounded  vessel  is  easily  and  sponta- 
neously accomplished.  In  deep  wounds,  with  restricted  external  wound, 
as  in  punctured  and  gunshot  wounds,  this  full  exposure  of  the  wounded 
vessel  is  equally  imperative.  Plugging  of  such  a  wound  with  tampons,  or 
compression  of  the  main  trunk  on  its  cardiac  side,  if  it  be  an  artery,  may 
be  resorted  to  as  means  of  temporary  arrest  of  bleeding ;  but  as  soon  as  the 
conditions  permit  the  methodical  dressing  of  the  wound,  the  vessel  must 

1  System  of  Surgery,  1882,  i.,  659. 


284  THE    TREATMENT    OF    WOUNDS. 

be  laid  bare  at  the  injured  point,  and  permanent  ligation  be  practised. 
For  this  purpose  free  incisions  must  be  made  through  the  skin  and  over- 
lying tissues,  always  making  them  of  sufficient  length  so  that  the  struct- 
ures at  the  bottom  of  the  resulting  wound  shall  be  distinctly  exposed  and 
readily  accessible  to  manipulation.  As  Esmarch  remarks  (International 
Medical  Congress,  London,  1881),  "  when  life  is  concerned,  it  matters  lit- 
tle whether  the  incision  be  an  inch  or  a  foot  long  ;  as,  if  it  succeed  in 
checking  haemorrhage,  and  be  conducted  thoroughly  aseptically,  a  long 
incision  heals  just  as  well  as  a  short  one." 

Care  to  first  render  the  limb  bloodless,  in  the  case  of  wounds  of  vessels 
of  the  extremities,  by  the  use  of  an  elastic  bandage,  after  the  method  of 
Esmarch,  will  greatly  facilitate  the  making  of  the  required  incisions.  Li 
other  cases,  a  finger  thrust  into  the  wound  so  as  to  reach  and  compress  the 
wound  in  the  vessel,  will  both  control  the  haemorrhage  for  the  time  being, 
and  will  serve  as  an  invaluable  guide  for  the  incisions.  As  the  incisions 
are  made,  all  blood-clots  should  be  thoroughly  and  carefully  removed  by 
sponging  and  scraping,  and  perfect  cleansing  of  the  wound  from  fluid 
blood  and  debris  of  every  kind  should  be  done.  When  the  wound  in  the 
vessel  has  been  found  and  exposed  sufficiently  to  enable  its  entire  extent  to 
be  seen,  the  vessel  must  be  isolated,  and  a  ligature  applied  to  a  healthy 
part  of  it  both  above  and  below  the  wound.  The  ligatures  must  be  asep- 
tic— catgut  or  silk — and  after  having  been  securely  tied,  should  be  cut  off 
close.  If,  by  misfortune,  no  aseptic  material  for  ligatures  can  be  obtained, 
necessity  will  compel  the  use  of  an  ordinary  thread.  In  this  case,  one  end 
having  been  cut  off  near  the  knot,  the  other  should  be  brought  out  at  the 
most  dependent  angle  of  the  wound. 

Esmarch  calls  attention  to  the  difficulty  that  may  be  experienced  in  dis- 
tinguishing veins,  when  bloodless  and  collapsed,  from  cords  of  connective- 
tissue.  As  a  means  of  overcoming  this,  he  advises  the  preliminary  forma- 
tion of  a  reservoir  of  blood  below  the  wound  by  placing  a  ligature  around 
the  hand,  for  instance,  before  applying  the  elastic  bandage  to  the  arm. 
Afterward,  on  elevating  the  limb  and  removing  the  ligature,  the  blood 
flows  out  of  the  injured  vein,  if  the  vessel  have  been  such. 

If  the  vessel  have  been  only  partially  divided  by  the  original  injury, 
after  the  ligatures  have  been  applied  on  either  side  of  the  wound,  the  divi- 
sion should  be  made  complete,  and  the  two  ends  allowed  to  retract 

The  direction  to  apply  a  ligature  to  the  distal  as  well  as  the  proximal 
side  of  a  vessel-wound  is  especially  applicable  to  wounds  of  arteries,  and  is 


WOUNDS   OF   BLOOD-VESSELS.  285 

to  be  observed  whether  the  distal  extremity  bleeds  when  exposed  or  not. 
If  left  unsecured,  imminent  risk  is  incurred  from  intermediary  haemor- 
rhage as  the  full  natural  force  of  the  circulation  begins  to  be  again  felt,  or 
from  secondary  haemorrhage  after  a  more  free  collateral  circulation  shall 
have  become  established. 

The  same  reasons  contra-indicate  the  practice  of  ligating  the  trunk  of 
the  artery  above  the  wound,  except  in  those  instances  in  which  the  bleed- 
ing artery  is  inaccessible,  as  the  internal  maxillary,  and,  in  some  instances, 
the  lingual 

In  the  treatment  of  wounds  of  small  vessels  lying  at  the  bottom  of  deep 
cavities,  and,  in  more  superficial  wounds,  where  a  general  bleeding  from 
many  small  vessels  persists,  in  which  the  application  of  ligatures  is  imprac- 
ticable, the  methods  which  have  been  described  are  impracticable,  and  the 
use  of  the  actual  cautery,  and  of  tampons  is  necessitated. 

Every  effort  should  be  made  to  secure  primary  union  in  wounds  that 
are  complicated  by  wounds  of  important  blood-vessels.  The  greatest  safe- 
guai'd  against  the  occurrence  of  secondary  dangers  from  wounds  of  the 
vessels  is  secured  by  preventing  disturbances  in  the  healing  of  the  general 
wounds  of  which  they  form  a  part.  Every  precaution  against  sepsis  which 
is  within  the  command  of  the  surgeon  should  be  practised  in  the  dressing 
and  after-treatment  of  these  wounds. 

COMPLICATIONS  OF  WOUNDS  OF  BLOOD-VESSELS. 

The  complications  which  are  so  especially  related  to  wounds  of  vessels 
as  to  demand  consideration  here,  are  the  losses  of  blood  which  are  liable 
to  attend  these  wounds.  Those  losses  which  follow  immediately  upon  the 
infliction  of  the  injury  constitute  primary  haemorrhage  ;  those  which  attend 
the  period  of  reaction,  constitute  intermediary  hcemorrhage  ;  and  those 
which  take  place  after  the  establishment  of  suppuration  constitute  second- 
ary hcemorrhage.  The  extensive  effusions  of  blood  which  follow  upon  the 
subcutaneous  rupture  of  large  blood-vessels,  known  as  traumatic  aneurisms, 
demand,  also,  some  consideration. 

PRIMARY  HAEMORRHAGE. — The  treatment  demanded  for  the  control  of 
this  complication  has  been  fully  considered  in  the  first  part  of  this  treatise, 
Chapter  VI.,  to  which  reference  should  be  made. 

INTERMEDIARY  HAEMORRHAGE. — The  treatment  of  intermediary  haemorrhage 
must  be  conducted  on  the  same  principles  as  those  which  guide  the  treat- 


286  THE   TREATMENT!   OF    WOUNDS. 

ment  of  primary  haemorrhage.  Its  occurrence  is  an  evidence  of  the  ineffi- 
ciency of  the  means  which  had  been  previously  instituted,  and  would 
hardly  take  place  in  any  case  if  the  directions  which  have  been  given  for 
the  full  exposure  of  wounded  vessels,  their  careful  ligation  in  a  sound  part 
of  their  structure  on  either  side  of  the  wound,  the  complete  division  of  the 
vessel,  if  previously  but  partially  divided,  and  the  removal  of  coagula  and 
debris  from  the  wound.  It  is  impossible  to  dwell  with  too  much  stress 
upon  the  importance  of  care  and  thoroughness  in  the  application  of  the 
first  dressing  as  a  preventive  of  subsequent  complications.  This  is  illus- 
trated by  the  list  of  causes  of  intermediary  haemorrhage  which  the  medical 
historian  of  the  War  of  the  Rebellion  gives  as  discernible  in  the  cases, 
seventy-seven  in  number,  which  appear  in  the  records  of  the  Surgeon-Gen- 
eral's office  of  the  army.1  The  report  states  that  "the  earlier  cases  of 
haemorrhage  were  due  to  the  force  of  the  blood-current  in  the  returning 
circulation  during  reaction  ;  to  commencing  inflammatory  action,  in  which 
the  swelling  had  been  sufficient  to  force  out  the  protective  coagulum  ;  to 
weakened  arterial  walls,  and  to  a  depraved  condition  of  the  blood  in  per- 
sons suffering  from  exhausting  or  depressing  diseases.  Not  unfrequently 
the  haemorrhage  of  the  earlier  days  had  its  source  in  the  injury  of  some 
vessel  of  considerable  size,  unnoticed  in  the  primary  examination  of  the 
wound.  Cases  have  been  cited  in  which  no  excessive  haemorrhage  was 
noticed  until  attempts  were  made  to  effect  the  removal  of  a  lodged  missile 
or  foreign  body,  which  had  prevented  bleeding  by  acting  as  a  plug  or 
tampon."  The  first  three  causes  in  this  list  are  the  result  of  failures  to 
primarily  expose  and  ligate  the  vessels.  The  last  two  to  want  of  thorough- 
ness in  the  primary  examination  of  the  wound.  Other  frequent  causes  of 
intermediary  haemorrhage,  such  as  the  inability  of  the  vessel  to  retract  by 
reason  of  its  incomplete  division,  the  imperfect  compression  of  the  vessel 
by  a  large  coagulum  which  has  been  permitted  to  accumulate  over  it,  act- 
ing the  rather  as  a  poultice  upon  it  to  keep  it  relaxed,  and  disturbance  of 
the  parts  by  muscular  spasm,  motion,  or  external  traumatism,  all  alike  are 
examples  of  infractions  of  the  primary  principles  of  wound-treatment 

The  occurrence  of  intermediary  haemorrhage  demands  at  once  a  new 
dressing  of  the  wound,  ab  initio.  It  must  be  opened,  enlarged  if  necessary, 
cleansed,  explored,  the  vessels  secured  as  already  described,  and  its  primary 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion.  Part  Third,  volume 
ii. ,  Surgical  History,  p.  809.  » 


SECONDARY    HAEMORRHAGE.  287 

dressing  and  after-treatment  conducted  scrupulously  in  accordance  with 
the  general  principles  and  methods  of  wound-treatment  already  described. 

Ligation  of  the  main  trunk,  the  use  of  the  actual  cautery  and  the  tam- 
pon are  resources  to  be  used  in  conditions  noted  on  a  previous  page  in  this 
chapter. 

SECONDABY  HJEMOKKHAGE. — Under  this  head  are  to  be  embraced  all  losses 
of  blood  from  wounded  vessels  occurring  after  the  establishment  of  sup- 
puration. Referring  again  to  the  "Medical  and  Surgical  History  of  the  War 
of  the  Rebellion"  (loc.  cit.),  we  find  the  statement  that  by  far  the  greater 
number  of  cases  of  secondary  haemorrhage  are  due  to  the  separation  of  a 
slough,  the  result  of  a  contusion  of  the  walls  of  the  vessel  and  the  inflam- 
matory action  consequent  upon  it.  Identical  in  nature  with  this  class  of 
cases  is  that  group  in  which  the  haemorrhage  takes  place  where  the  ulcera- 
tion  of  the  vascular  coats,  produced  by  the  constriction  of  an  irritating 
ligature,  is  accomplished,  without  the  previous  obliteration  of  the  adjacent 
portion  of  the  vessel  by  adhesive  inflammation. 

Yet  other  cases  have  their  origin  in  the  breaking  down  of  adhesions,  or 
the  progressive  ulceration  of  tissue  due  to  the  changes  effected  in  the 
wound  by  destructive  inflammatory  and  septic  processes. 

Neglect  to  secure,  by  ligature,  the  distal  orifice  of  a  severed  vessel  may 
be  the  cause  of  a  later  haemorrhage,  after  the  collateral  circulation  shall 
have  become  sufficiently  free  to  restore  the  strength  of  the  blood-current 
hi  that  portion  of  the  vessel. 

Faulty  application  of  the  ligature  in  the  primary  dressing  ;  subsequent 
increase  of  blood-pressure  as  the  result  of  venous  thrombosis,  or  inflamma- 
tory engorgement,  or  improper  position  of  the  wounded  part ;  interference 
with  repair  by  muscular  spasm,  motion,  or  external  traumatism  ;  constitu- 
tional conditions  that  interfere  with  repair  ;  these  should  be  added  to  the 
list  of  causes  that  may  determine  a  secondary  hsemorrhage. 

This  statement  of  the  causes  of  secondary  haemorrhages  is  a  record  of 
failures  either  to  institute  or  to  carry  out  the  primary  principles  of  wound- 
treatment.  It  enforces  the  injunction  already  given  to  observe  with  scru- 
pulous care,  in  the  treatment  of  wounds  involving  the  opening  of  large 
blood-vessels,  every  precaution  which  shall  prevent  the  access  of  disturb- 
ance in  its  repair,  and  shall  foster  the  most  rapid  union  throughout  its 
extent. 

The  appearance  of  secondary  hsemorrhage  from  a  wound,  even  though 
it  at  first  be  small  in  amount,  should  at  once  engage  the  effort  of  the  sur- 


288  THE    TREATMENT    OF    WOUNDS. 

geon  for  the  application  of  efficient  means  for  arresting  it  and  preventing 
its  renewal  Only  the  most  radical  measures  should  be  employed.  Even 
though  the  haemorrhage,  either  spontaneously  or  as  the  result  of  superfi- 
cial applications,  have  ceased  at  the  time,  its  recurrence  again  and  again  is 
certain,  unless  adequate  proceedings  for  its  control  be  at  once  instituted. 
The  opening  in  the  vessel  must  be  sought  for  and  exposed,  and  ligatures 
placed  on  both  its  distal  and  proximal  sides  at  points  where  the  vascular 
tissue  is  sound.  This  rule  is  subject  to  those  exceptions  only  which  have 
already  been  noticed  in  connection  with  the  treatment  of  intermediary 
haemorrhage. 

DIFFUSE  TRAUMATIC  ANEURISM. — The  same  principles  which  are  applica- 
ble to  open  wounds  apply  also  to  the  treatment  of  rapidly  extending  effu- 
sion of  blood  from  subcutaneous  wounds  of  large  blood-vessels.  Nor 
should  the  treatment  be  delayed  till  the  effusion  has  attained  a  threaten- 
ing magnitude.  The  surgeon  should  proceed  at  once  to  expose  the  wound 
by  external  incisions,  ligate,  cleanse,  dress,  and  immobilize,  as  in  the  case 
of  other  wounds. 

WOUNDS  OF  VEINS. 

In  some  instances  the  treatment  of  wounds  of  veins  may  justifiably 
vary  from  that  which  would  be  imperative  for  wounds  of  arteries  of  the 
same  importance.  Such  variations  are  dependent  upon  the  differing 
anatomical  and  physiological  conditions  of  the  two  classes  of  blood-vessels, 
and  also  upon  the  different  course  which,  in  consequence,  their  repair 
may  take. 

The  tendency  to  gaping  of  the  wound,  in  the  case  of  a  vein-injury,  is 
less  than  in  a  similar  wound  of  an  artery ;  the  greater  thinness  of  the  walls 
of  veins  causes  them,  as  tubes,  to  be  more  flaccid  and  to  collapse  sponta- 
neously when  empty,  while  the  more  languid  and  even  flow  of  blood 
through  them,  and  the  freer  collateral  circulation,  reduces  greatly  the  force 
with  which  they  are  distended  by  their  contents.  From  these  circum- 
stances apposition  of  divided  surfaces  is  more  readily  secured  and  main- 
tained in  them,  as  a  class,  than  in  similar  wounds  in  arteries,  and  the 
provisions  of  "  rest "  during  repair  are  less  likely  to  be  violated.  As  a  con- 
sequence, the  repair  of  vein-wounds  is  often  rapid  and  perfect,  and  union 
of  incomplete  wounds  may  even  be  accomplished  in  many  instances  with- 
out obliterating  the  canal  of  the  vessel  Such  a  result,  as  a  rule,  is  ob- 
tained in  cases  of  longitudinal  wounds  of  superficial  veins,  when  the 


WOUNDS    OF    VEINS.  289 

treatment  is  confined  to  the  application  of  simple  external  compression. 
The  pressure  of  the  compress  suffices  to  exclude  the  column  of  blood  from 
the  wounded  region  until  adhesion  of  the  edges  of  the  wound  in  the  wall 
of  the  vein  has  taken  place.  Upon  the  withdrawal,  then,  of  the  compres- 
sion, the  blood  renews  its  course  through  its  previous  channel 

In  the  case  of  wounds  partially  dividing  a  large  and  deep-seated  vein, 
the  size  of  the  vessel  and  the  flaccidity  of  its  walls  may  permit  the  edges 
of  such  an  incomplete  wound  and  some  of  the  inner  tunic  adjoining  to  be 
brought  together  and  held  in  apposition  by  ligatures,  sutures,  or  clamps, 
until  firm  adhesion  has  taken  place,  without  interruption  to  the  flow  of 
blood  through  the  vein  at  any  time.  No  such  thing  is  possible  in  the  case 
of  any  arterial  wound. 

The  direction  of  the  blood-current  in  the  veins  toward  the  heart,  and 
the  continually  increasing  calibre  of  the  channels  through  which  it  passes 
cauae  the  occurrence  of  disturbances  of  repair  in  wounds  in  which  veins 
are  involved,  or  even  exposed,  to  be  attended  with  special  dangers,  either 
from  dislodgement  of  a  loosened  clot  or  mass  of  fibrinous  exudate,  or  from 
the  production  therein  of  more  liquid  and  septic  secretions  that  flow  into 
and  mingle  with  the  general  mass  of  the  blood. 

The  loose  connective-tissue  in  which  veins  are  embedded,  and  which 
forms  for  them  a  kind  of  sheath,  has  been  observed  to  afford  most  favorable 
conditions  for  the  development  and  diffusion  of  septic  phlegmonous  wound- 
inflammations,  in  the  course  of  which  the  tunics  of  the  vessels  themselves 
become  involved,  and  disastrous  phlebitis  may  ensue. 

Mr.  Benjamin  Travers,  in  his  essay  on  "Wounds  and  Ligatures  of 
Veins,"  which  was  published  in  1811,  seems  to  have  been  the  first  to  draw 
special  attention  to  the  dangers  attending  injuries  of  veins.  He  speaks  of 
the  "  fatal  catalogue  of  tied  veins,"  and  says  that  he  has  observed  some- 
thing like  that  superstitious  alarm  which  is  excited  by  events  that  we  do 
not  expect  and  cannot  explain,  when  such  a  catalogue  is  compared  with  the 
generally  successful  cases  of  tied  arteries.  In  the  period  immediately  pre- 
ceding the  time  when  Travers  wrote,  there  had  been  an  entire  absence  of  ap- 
prehension of  danger  in  dealing  with  veins,  so  that,  in  the  language  of  that 
writer,  they  were  attacked  with  singular  rudeness,  pricking,  cutting,  tying, 
and  burning  them,  without  ever  adverting  to  any  other  than  the  mechan- 
ical effects  of  such  operations  upon  the  diseases  for  which  they  were  insti- 
tuted. 

This  author  was  successful  in  awakening  attention  to  the  fact  that  dis- 
19 


290  THE    TREATMENT    OF    WOUNDS. 

astrous  inflammatory  complications  often  followed  injuries  of  veins;  that 
they  sometimes  followed  a  puncture,  sometimes  a  division,  a  ligature  encir- 
cling the  tube,  or  including  only  a  part  of  it ;  or  that  they  sometimes  arose 
spontaneously  from  an  inflamed  surface,  of  which  the  vein  formed  a  part. 
The  practice  of  phlebotomy,  though  involving  only  a  simple  longitudinal 
wound  of  a  superficial  vein,  by  the  great  frequency  with  which  it  was  per- 
formed, afforded  many  examples  of  the  accidents  that  might  follow  such 
wounds.  Trousseau  and  Pigot,  in  1827,  testified1  that  every  year  they 
witnessed  fatal  inflammatory  complications  supervening  upon  phlebotomy. 
By  many  surgeons  veins  came  to  be  regarded  as  vessels  especially  intoler- 
rant  of  interference,  and  prone  to  the  development  of  unexpected  and  un- 
controllable complications.  Ligation  of  veins,  in  particular,  became  con- 
sidered as  hazardous.  Many  of  the  surgical  writers  of  the  second  quarter 
of  the  present  century,  including  Roux,  Lisfranc,  Langenbeck,  Miller,  and 
Pirogoff,  taught  that  it  was  attended  with  great  danger,  and  to  be  avoided 
by  all  possible  means.  Dupuytren4  spoke  of  phlebitis  as  "that  inflamma- 
tion so  grave,  so  difficult  to  master,  which  has  caused  so  great  a  number 
of  persons  to  perish  whose  veins  have  been  ligated."  Chassaignac s  taught 
that  ligation  was  one  of  the  most  dangerous  operations  of  surgery,  and 
more  recently,  Erichsen,4  that  the  application  of  a  ligature  to  a  vein 
"should,  if  possible,  always  be  avoided." 

A  numerical  majority  of  surgeons,  however,  have  always  held  that  the 
dangers  of  the  ligation  of  veins  were  not  sufficiently  imminent  to  prevent 
its  adoption  as  a  measure  of  convenience  in  the  treatment  of  a  wound. 

No  difference  of  opinion  has  existed,  however,  as  to  the  hazards  attend- 
ing the  ligation  of  veins  whose  tunics  were  diseased,  as  in  the  case  of  vari- 
cose veina 

The  occurrence  of  thrombosis  and  suppurative  peri-phlebitis  has  been 
observed  as  particularly  likely  to  be  provoked  in  instances  in  which  veins 
have  been  contused  or  denuded.  In  three  instances,  one  surgeon — Oilier, 
of  Lyons — is  reported 6  to  have  seen  death  follow  in  from  eighteen  to  thirty- 
six  hours  after  the  beginning  of  a  thrombosis  complicating  a  wound  of 
this  character.  From  this  experience  he  concluded  that  extensive  denuda- 

1  Archives  Generates  de  Medecine,  1827. 

1  Lemons  Orates  de  Clinique  Chirurgicale,  1839,  t.  iii.,  p.  251. 

8  Traite  Clinique  et  Pratique  des  Operations  Chirurgicales,  t.  i. 

4  Science  and  Art  of  Surgery,  1878,  vol.  i.,  p.  278. 

5  Nicaise  :  Des  Plaies  et  de  la  Ligature  des  Veines,  1872,  p.  42. 


WOUNDS    OF    VEINS.  291 

tion  of  a  vein  is  more  dangerous  than  ligation ;  and  that  in  cases  in  which 
immediate  union  is  not  obtained  after  such  denudation,  when  sloughing  of 
the  flaps  that  cover  the  veins  occurs,  when,  in  a  word,  the  veins  remain  ex- 
posed at  the  bottom  of  a  suppurating  wound,  all  the  accidents  of  an  exten- 
sive and  progressive  thrombosis  are  likely  to  occur.  These  complications, 
however,  are  not  the  inevitable  consequences  of  denudation  and  contusion, 
for  such  injuries,  in  the  greater  number  of  instances,  progress  to  recovery 
without  their  development 

Physiological  experiment  has  fully  demonstrated  that  the  tunics  of  a 
vein  do  not  possess  a  special  intolerance  that  renders  them  liable  to  de- 
structive inflammation  more  quickly  and  upon  less  irritation  than  other 
tissues.  The  more  frequent  connection  of  wounds  of  veins,  than  of  their 
companion  vessels,  the  arteries,  with  diffuse  suppurative  inflammations  and 
profound  and  rapid  general  intoxication,  is  not  a  myth,  nevertheless.  It 
results  from  the  readiness  with  which  the  connective-tissue  that  ensheathes 
the  veins  permits  the  progressive  invasion  of  micro-organisms,  and  from 
the  fact  that  the  resulting  peri-phlebitis  determines  the  formation  of  coagula 
in  the  involved  vein,  which,  in  their  turn,  are  likely  to  be  speedily  invaded 
by  micro-organisms,  and  thus  become  converted  into  poison-depots,  from 
which  ptomaines,  pus,  and  emboli  are  discharged  directly  into  the  circu- 
lation. 

These  dangers  require  to  be  considered,  and  to  engage  the  careful 
effort  of  the  surgeon  for  their  prevention  in  all  cases  of  wounds  of  veins. 

The  effect  of  the  constriction  of  a  vein  by  a  ligature  does  not  introduce 
any  new  danger  into  the  wound.  The  evil  effects  which  have  been  noted 
as  prone  to  occur  in  wounds  in  which  ligation  of  a  vein  has  been  performed, 
arise  only  in  those  cases  in  which  the  material  of  the  ligature  is  irritating, 
and  is  so  applied  as  to  become  the  means  of  the  introduction  or  retention 
of  septic  matter  in  the  wound.  Whenever  an  ordinary  ligature  is  applied, 
the  constricting  thread  is  an  irritating  foreign  body  in  the  wound,  and 
invariably  excites  along  its  track  an  inflammation  which  persists  until  its 
removal  is  permitted  by  the  division,  by  ulceration,  of  the  walls  of  the 
constricted  vein — a  period  of  time  extending  upon  an  average  from  one  to 
two  weeks,  according  to  the  size  of  the  vein.  Union  by  first  intention  is 
thus  prevented,  along  the  track  of  the  ligature  at  least  The  thread,  satur- 
ated with  the  secretions  of  the  suppurating  sinus  which  it  has  created, 
becomes  the  best  media  for  transmitting  septic  germs  to  the  deepest  part 
of  the  wound.  The  irritation  of  its  presence  puts  an  additional  strain  upon 


292  THE    TREATMENT    OF    WOUNDS. 

the  resisting  power  of  the  tissues  among  which  it  lies,  and  to  this  extent 
lessens  their  ability  to  resist  invasion  when  septic  germs  find  access  to  the 
wound. 

The  natural  resisting  power  of  the  tissues  is  sufficient  to  limit,  in  the 
great  majority  of  cases,  the  amount  of  disturbance  resulting  from  an  ordi- 
nary ligature  to  a  circumscribed  inflammation,  which  simply  mats  together 
the  tissues  adjacent  to  the  ligature,  and  confines  the  destructive  processes 
to  necrosis  of  the  tissue  grasped  in  the  loop  of  the  thread.  But  in  cases 
in  which  original  defective  resisting  power  exists,  as  notably  in  tissues 
whose  nutrition  has  been  interfered  with  by  the  varicosity  of  their  veins, 
and  in  those  in  which  some  general  cachexia  pre-exists,  an  unchecked  dif- 
fusion of  the  disturbances  introduced  by  such  a  ligature  would  be  likely 
to  take  place. 

These  considerations,  as  to  the  sources  of  the  disturbances  which  have 
been  observed  to  complicate  vein-wounds,  show  the  importance  of  elimin- 
ating them,  not  only  in  cases  where  veins  already  diseased  exist,  but  also 
in  all  cases  in  which  vein-wounds  demand  special  means  for  the  control  of 
haemorrhage  and  the  maintenance  of  the  walls  in  apposition.  They  justify 
the  dread  of  ligation  which  has  been  felt  by  many  surgeons,  practised,  as 
it  has  been,  with  an  irritating  thread,  and  they  emphasize  the  importance 
of  employing  substitutes  for  such  ligatures,  so  that  full  compliance  with 
the  requirements  of  surgical  cleanliness  and  of  wound-protection  may  be 
accomplished  in  the  treatment  of  this  class  of  wounds. 

Acupressure  and  forcipressure  both  present  great  advantages  over  the 
common  ligature  as  methods  for  controlling  venous  haemorrhages,  and 
few  conditions  will  be  found  in  which  one  or  other  of  them  may  not  be 
substituted  for  the  ligature.  The  retention  of  the  compressing  needle  or 
forceps  is  rarely  necessary  for  a  longer  period  than  a  few  hours.  Their 
smooth  metallic  surfaces  do  not  irritate  the  wound  ;  they  may  be  enclosed 
in  the  antiseptic  protective  material  that  may  be  available  for  dressing  the 
wound ;  and  their  early  withdrawal  removes  the  mechanical  obstacles  to 
primary  union  that  they  cause  during  their  residence  in  the  wound. 

The  value  of  forcipressure  is  illustrated  by  the  following  case  : 

CASE. —  Wound  of  Internal  Jugular  Vein — Lateral  Forcipressure — Re- 
covery.— In  November,  1881,  W.  B.,  aged  about  45  years,  stabbed  himself 
in  the  neck  with  a  small  dagger.  The  weapon  was  thrust  into  the  right 
side  of  the  neck,  passed  through  the  sterno-cleido-mastoid,  grazed  the  in- 
ternal jugular,  in  which  it  inflicted  a  small  lateral  wound,  and  finally  pene- 


WOUNDS    OF    VEINS. 

trated  the  trachea.  The  wife,  who  was  at  his  side  in  a  moment,  restrained 
the  haemorrhage  by  throwing  her  arm  around  his  neck  so  as  to  compress 
the  wound.  Dr.  James  E.  Pilcher  was  at  the  side  of  the  patient  in  a  few 
minutes.  He  enlarged  the  wound  sufficiently  to  identify  the  vessel  and 
expose  the  opening  into  it,  which  was  a  simple  slit  in  its  anterior  wall,  a 
quarter  of  an  inch  in  length.  He  first  applied  a  lateral  ligature  ;  but  exten- 
sion of  the  neck,  caused  by  the  falling  back  of  the  patient's  head,  as  he  was 
being  placed  in  bed,  caused  this  to  slip  off.  Haemostatic  forceps  were  then 
applied,  which,  perfectly  controlling  the  haemorrhage,  were  left  to  produce 
permanent  obliteration  of  the  wound  in  the  vein.  On  the  second  day 
thereafter  they  were  removed.  No  further  haemorrhage  took  place.  The 
wound  healed  by  granulation,  and  a  perfect  recovery  was  accomplished. 

In  this  case  the  forceps  were  kept  in  situ  for  a  period  of  about  thirty- 
six  hours  ;  but  in  most  cases  in  which  I  have  used  them,  as  in  wounds  of 
veins  in  the  axilla  or  in  the  neck,  I  have  been  able  to  remove  them  in  a 
much  shorter  time. 

In  general,  however,  a  more  excellent  way  still  is  available  to  the  sur- 
geon in  dealing  with  wounded  veins.  For,  as  acupressure  needles  and 
haemostatic  forceps  excel  the  ordinary  ligatures,  so  they,  in  turn,  are  ex- 
celled by  the  aseptic  animal  ligature  and  antiseptic  protective  dressings,  by 
which,  with  a  perfect  haemostatic,  easily  and  universally  applicable,  that 
provokes  no  irritation  by  its  presence  in  the  tissues,  and  that  is  sponta- 
neously removed  by  absorption  when  no  longer  needed,  security  is  also 
guaranteed  against  the  access  from  without  of  agencies  that  might  disturb 
repair.  By  the  use  of  such  an  aseptic  ligature,  it  becomes  possible  to 
avoid  the  sources  of  disturbance  that  have  thus  far  been  recognized  in 
wounds  of  veins,  and  to  make  the  application  of  a  ligature  safe  in  all  cases. 

For  the  purpose  of  obtaining  more  definite  data  upon  which  to  base 
the  employment  of  the  ligature  in  treating  vein-wounds,  I  made  a  number 
of  experiments  during  the  year  1882  upon  goats,  using  aseptic  catgut  My 
experiments  included  three  ligations  of  the  internal  jugular  vein,  and  two 
of  the  femoral  vein.1  Union  by  first  intention  of  the  operation  wound  was 
secured  in  each  instance.  As  the  result  of  these  operations  I  secured 
specimens  illustrating  the  condition  of  repair  upon  the  second,  fourth, 
ninth,  fourteenth,  and  twenty-fourth  days  after  ligation.  Examination  of 
them  demonstrated  that  marked  proliferation  of  the  tissue-cells  of  the 
tunica  interna  had  been  excited,  the  activity  of  this  proliferation  being 

1  The  Use  of  Ligatures  in  Wounds  of  Veins.     Medical  News,  Phila.,  1883,  xlii.,  278. 


294  THE    TREATMENT    OF    WOUNDS. 

greater  as  the  point  where  the  vein  walls  were  constricted  and  approxi- 
mated by  the  ligature  was  approached.  The  accumulation  and  confluence 
of  the  mass  of  cells  in  the  cul-de-sac  formed  by  the  vein-constriction,  the 
subsequent  extension  of  capillaries  into  them,  and  the  consequent  conver- 
sion of  the  new  tissue  into  connective-tissue,  were  the  successive  steps  by 
which  permanent  closure  of  the  tied  veins  was  effected.  In  none  of  these 
experiments  did  a  thrombus  form  on  either  side  of  the  ligature,  except  in 
one  case,  in  which  special  effort  was  made  to  secure  one  by  applying  a 
second  ligature  to  the  vein,  swollen  with  blood,  a  little  more  than  an  inch 
above  the  first  one.  The  part  of  the  vein  between  the  two  ligatures  having 
been  left  filled  with  blood,  a  thrombus  was  thus  obtained.  The  specimen 
was  removed  on  the  ninth  day.  In  this  case  the  clot  was  found  to  have 
simply  mechanically  distended  the  tunics  of  the  vessel,  making  the  study 
of  the  conditions  presented  by  the  tunics  more  easy,  but  not  modifying  the 
character  of  the  reparative  process.  It  was  an  unirritating  injection-mass 
that  was  awaiting  to  be  invaded  and  appropriated  by  active  cells  from  the 
adjacent  tissue. 

The  reparative  changes  which  had  been  provoked  by  the  application  of 
the  ligature  may  be  regarded  as  having  had,  as  their  first  object,  the  resto- 
ration of  function  in  parts  whose  nutrition  had  been  disturbed  by  the  orig- 
inal application  of  the  ligature.  But  the  agent  which  had  disturbed  the 
nutrition  of  the  tunica  interna,  and  provoked  a  more  active  metamorphosis 
and  proliferation  of  its  cell-elements,  had  at  the  same  time  held  the  vein- 
walls  in  coaptation  until  the  confluent  plastic  material  formed  had  become 
sufficient  in  amount  and  tenacity  to  permanently  unite  them  together. 
Essentially  the  process  is  that  of  the  formation  of  a  cicatrix,  and  in  its 
course  the  ligature  plays  the  same  part  as  does  the  suture  in  ordinary 
wounds — that  of  maintaining  coaptation  until  firm  adhesion  is  secured. 
There  may  be  seen  in  this,  also,  the  same  process  as  that  by  which  a  sim- 
ple longitudinal  slit  in  a  vein-wall  may  be  repaired  without  obstruction  to 
the  current  of  blood  through  the  vessel,  the  edges  of  the  slit  themselves 
furnishing  the  material  for  its  repair,  the  amount  of  which  material,  if  only 
further  irritation  or  traumatism  be  withheld,  being  strictly  limited  to  the 
reparative  needs  of  the  injured  structures. 

The  two  following  cases,  from  Lidell,1  may  be  quoted  as  involuntary 
experimental  demonstrations  on  the  human  subject  of  the  repair  of  vein 

1  Injuries  of  Blood-vessels.  International  Encyclopaedia  of  Surgery,  iiL,  115  and 
197. 


THE    REPAIR    OF    VEIN-WOUNDS.  295 

wounds,  when  undisturbed.     The  first  case  occurred  in  the   practice  of 
Professor  S.  D.  Gross  : 

CASE  L — A  strumous  lad,  aged  14,  was  wounded  in  the  neck  by  an  ac- 
cidental discharge  of  a  fowling-piece,  loaded  with  large-sized  squirrel-shot, 
which  entered  the  neck  at  four  or  five  different  points.  The  casualty  was 
attended  with  but  little  haemorrhage,  and  the  symptoms  of  shock  soon 
passed  away.  The  wounds  healed  without  any  application,  and  everything 
went  well  until  thirteen  days  after  the  accident,  when  the  patient  was 
seized,  suddenly  and  without  warning,  by  a  protracted  epileptic  convul- 
sion, affecting  chiefly  the  left  side,  and  died  the  following  day,  without  re- 
turn of  consciousness.  Autopsy. — One  shot  had  perforated  the  subclavian 
artery,  and  had  lodged  in  the  first  rib.  The  calibre  of  the  vessel  was  un- 
impaired, and  the  apertures  were  closed  by  small  clots  extending  around 
the  exterior  of  the  vessel,  upon  the  removal  of  which  the  margins  of  the 
wounds  appeared  as  if  they  had  just  been  inflicted.  The  artery  presented 
no  marks  of  inflammation. 

Another  shot  had  perforated  the  anterior  wall  of  the  right  internal 
jugular  vein,  and  had  lodged  on  the  inner  surface  of  the  opposite  wall, 
where  it  had  become  completely  encysted.  The  vein  bore  no  evidence  of 
inflammation.  The  opening  in  the  anterior  wall  was  perfectly  closed,  and 
there  was  no  external  nor  internal  clot.  The  lumen  of  the  vein,  however, 
was  somewhat  diminished  by  the  projecting  cyst. 

CASE  IL — Professor  Langenbeck,  while  removing  an  epithelial  cancer, 
wounded  the  internal  jugular  vein,  and  tied  the  cardiac  end  only,  there 
being  no  haemorrhage  from  the  distal  end.  The  common  carotid  artery, 
being  involved  in  the  tumor,  was  tied  with  two  threads  and  divided. 
When  operated  on,  the  man  had  bronchitis,  from  which  he  died  on  the 
twelfth  day.  A  necroscopy  showed  the  vein  completely  healed,  as  if  by  the 
first  intention,  without  the  slighest  trace  of  redness,  thickening  of  its  walls, 
or  formation  of  a  clot. 

LATERAL  LIGATION. 

The  considerations  which  have  been  described,  as  to  the  process  of  re- 
pair after  ligation  of  veins  with  unirritating  ligatures,  find  an  important 
practical  application  in  determining  the  propriety  of  substituting  a  lateral 
ligature,  or  a  lateral  suture,  for  ligatures  encircling  the  entire  vessel  in  the 
treatment  of  wounds  involving  but  a  portion  of  the  wall  of  a  great  vein. 

The  use  of  lateral  ligatures  has  been  strongly  condemned  by  many 


296  THE   TREATMENT    OF    WOUNDS. 

surgical  writers.  Malgaigne  !  says,  "  the  lateral  ligature  will  be  an  opera- 
tion always  to  be  condemned,"  and  that  "  for  very  extensive  wounds  of 
venous  trunks,  where  compression  is  insufficient,  the  only  resource  is  the 
ordinary  ligature."  The  objection  of  this  author  was  founded  on  the 
erroneous  belief  that  permanent  haemostasis  after  a  vein-wound  depended 
upon  the  formation  of  a  clot  sufficient  to  occlude  the  entire  lumen  of  the 
wounded  vessel  Inasmuch,  therefore,  as  the  lateral  ligature  in  some  cases 
might  fail  to  provoke  the  formation  of  such  a  clot  when  the  ligature  should 
come  away,  in  such  cases  secondary  haemorrhage  would  be  inevitable.  The 
objection  of  all  surgeons  who  have  rejected  this  measure  as  a  justifiable 
proceeding,  has  arisen  from  the  frequency  with  which  secondary  haemor- 
rhage has  occurred  in  the  cases  in  which  it  has  been  employed. 

Braun  *  has  compiled  from  published  records  twenty-four  cases  in 
which  a  lateral  ligature  was  applied,  and  three  cases  of  lateral  forcipress- 
ure.  Of  these  nine  died  from  pyaemia  and  from  secondary  haemorrhage. 
In  one  case  the  ligature  slipped,  and  the  haemorrhage  had  to  be  controlled 
by  other  means.  In  thirteen  of  these  cases,  the  internal  jugular  vein  was 
the  vessel  wounded.  Lateral  ligature  was  applied  in  twelve  instances,  and 
forcipressure  in  one.  Three  deaths  resulted  from  secondary  haemorrhage. 
In  seven  instances  the  femoral  vein  was  involved.  Lateral  ligature  was 
apph'ed  in  five  cases,  and  forcipressure  in  two.  There  was  One  death  from 
secondary  haemorrhage,  caused  by  the  slipping  off  of  the  ligature,  and  five 
deaths  from  pyaemia.  Five  cases  in  which  the  axillary  vein,  one  in  which 
the  subclavian,  and  one  in  which  the  external  jugular  were  involved,  all 
recovered. 

The  deaths  from  pyaemia  were  all  due  to  septic  hospital  influences,  and 
are  not  to  be  attributed  in  any  way  to  the  special  method  of  ligation 
adopted.  The  proportion  of  cases  of  secondary  haemorrhage,  however,  is 
so  great  that,  unless  the  danger  of  such  a  complication  can  be  shown  to  be 
avoidable,  the  practice  must  be  condemned,  since  its  dangers  outweigh  any 
advantages  that  might  otherwise  attach  to  it 

These  disasters,  however,  have  occurred  in  connection  with  the  use  of 
ordinary  ligatures,  the  dangers  of  which,  even  for  use  in  ligations  of  the 
whole  circumference  of  a  vein,  have  been  dwelt  upon,  and  such  use  depre- 
cated. Much  more  imminent  is  the  danger  which  their  use  entails  when 

1  Medecine  Operatoire,  ed.  1861,  p.  114. 

*  Ueber  den  seiUicfien  VerscJduss  von  Venenwunden.  Archivfur  Jdinische  chirurgit, 
1882,  xxviii.,  654-4572. 


LATERAL    LIGATION    OF    VEINS.  297 

applied  to  the  side  of  a  vein.  In  many  cases,  as  Malgaigne  feared,  no  clot 
would  have  formed  to  act  as  a  plug  to  the  hole  in  the  vein  produced  by 
the  separation  of  the  slough  grasped  in  the  loop  of  the  ligature,  nor  would 
a  sufficient  amount  of  plastic  exudate  have  gathered  on  the  interior  of  the 
pucker,  at  the  site  of  the  ligature,  to  substitute  a  wall  of  new  tissue  for 
that  carried  away  by  the  slough.  Secondary  haemorrhage,  in  such  cases,  is 
inevitable.  Lateral  ligation,  therefore,  should  not  be  employed  when  the 
surgeon  must  make  use  of  an  ordinary  thread  for  his  ligature.  In  such 
cases  the  entire  vessel  must  be  included  in  the  ligature,  which  must  be 
applied  both  above  and  below  the  wound,  and  complete  division  of  the 
vessel  between  the  ligatures  be  done. 

The  use  of  aseptic  materials  for  ligatures,  which  may  be  cut  short,  and 
over  which  speedy  union  of  the  entire  wound  by  first  intention  may,  with 
much  certainty,  be  secured,  places  the  subject  of  lateral  ligature  upon  an 
entirely  different  basis.  Care  is  first  necessary  that  the  ligature  is  securely 
applied,  lest  the  accident  of  its  slipping  off  should  expose  to  disaster. 
Then  the  rent  in  the  wall  is  virtually  transformed  into  an  extravascular 
injury,  and  the  tissues  of  the  puckered  wall  of  the  vein,  in  the  grasp  of  the 
ligature,  are  placed  in  the  same  condition  as  that  which  characterizes  veins 
when  ligated  in  their  whole  circumference.  No  thrombus  is  required,  nor 
formed,  by  its  insufficiency  or  its  disintegration,  to  become  a  source  of 
danger.  There  is  no  ulcerative  process  to  extend  unduly,  and  to  leave  an 
opening  in  the  vein-wall  when  the  ligature  comes  away.  That  the  process 
of  the  exudation  and  complete  organization  of  the  plastic  material  that  fills 
in  and  effaces  the  irregularity  produced  by  the  application  of  the  ligature 
should  proceed  undisturbed  to  its  conclusion,  demands,  simply,  that  the 
general  precautions  for  securing  wound-repair  be  observed.  The  ligature 
acts  as  an  unirritating  reinforcement  that  prevents  the  rupture  of  this  new 
tissue  during  the  yielding  period  of  its  history,  and  itself  is  finally  disinte- 
grated, and  is  removed  in  the  course  of  the  ordinary  tissue  changes  of  the 
part. 

Practised  with  aseptic  materials — catgut  or  silk — with  antiseptic  pre- 
cautions, lateral  ligature  is  a  safe  and  valuable  means  of  treatment  in 
wounds  of  the  lateral  walls  of  veins.  It  should  especially  be  employed  in 
the  case  of  wounds  of  the  main  veins  at  the  roots  of  the  extremities,  as  the 
axillary,  subclavian,  and  femoral,  the  complete  closure  of  which  would  be 
likely  to  seriously  disorder  the  circulation  of  the  limb  of  whose  blood  it  is 
the  channel  of  return  to  the  heart. 


298  THE    TREATMENT   OF    WOUNDS. 

LATERAL  SUTURE. 

The  application  of  a  suture  suggests  itself  as  a  resource  in  lateral 
wounds  of  large  veins,  when  such  wounds  are  too  long  or  extensive  to  admit 
of  being  closed  by  a  lateral  ligature.  Cheyne  relates  '  the  following  case, 
in  which  this  procedure  was  adopted  by  Mr.  Lister :  In  removing  some 
cancerous  glands  from  the  axilla,  a  small  vein  was  torn  away  from  the  axil- 
lary vein  at  their  junction,  making,  practically,  a  longitudinal  rent  in  the 
axillary  vein.  Taking  a  fine  curved  needle  and  the  finest  catgut,  he  stitched 
up  the  rent  by  the  glover's  suture.  The  patient  recovered  without  the 
slightest  bad  symptom. 

Braun  (op.  citat)  relates  that  Czerny  performed  this  operation  upon 
the  internal  jugular  vein,  but  haemorrhage  recurred  so  that  acupressure 
became  necessary.  Schede  was  more  fortunate.  He  stitched  the  femoral 
vein  with  a  fine  needle  and  the  finest  of  catgut  He  then  sutured  also  the 
sheath  of  the  vessel  Union  by  first  intention  followed. 

The  same  considerations  are  applicable  to  the  lateral  suture  which  have 
been  elaborated  in  connection  with  the  lateral  ligature.  When  it  is  per- 
formed, the  edges  of  the  wound  in  the  vein  should  be  brought  out  so  that, 
as  the  thread  is  drawn  up,  the  internal  surfaces  of  the  divided  vein  flaps 
shall  be  brought  in  contact  Upon  a  large  vein  like  the  internal  jugular, 
it  might  be  found  practicable  to  hold  the  wound-edges  together  by  a 
"  through-and-through "  continuous  stitch,  instead  of  by  the  ordinary 
"  over-and-over "  glover's  stitch.  This  would  bring  the  surfaces  of  the 
intima  into  more  certain  and  extensive  contact,  and  therefore  would  be 
preferable.  Silk — aseptic — is  to  be  chosen  for  the  suture  material  on  ac- 
count of  the  greater  ease  and  certainty  with  which  it  may  be  manipulated. 
A  very  fine  strand  is  to  be  used.  The  ordinary  round  sewing  needle  of  the 
sempstress  should  be  employed  for  introducing  the  suture,  since  the  punc- 
ture which  it  makes  will  be  more  perfectly  filled  by  the  thread  that  is 
drawn  after  it  than  when  a  needle  with  cutting  edges  is  used. 

1  Antiseptic  Surgery,  76. 


PART   II. 

SPECIAL    WOUNDS 


SECTION  III. 
WOUNDS  OF  SPECIAL  EEGIONS. 


CHAPTER  XVIII. 
WOUNDS  OF  THE  HEAD. 

Anatomical  Considerations — Superficial  Wounds  of  Scalp — Bruises  and  Contusions — 
Punctured  and  Incised  Wounds — Extensive  Lacerations — Superficial  Gunshot 
Wounds — Deep  Wounds  of  Scalp  with  Injuries  to  the  Cranium — Signs  of  Compres- 
sion of  Brain  Absent — Fractures  of  the  Skull — Indications  for  Trephining — Frac- 
tures of  the  Base  of  the  Skull — Compression  of  the  Brain — Wounds  of  Intracranial 
Vessels  and  Sinuses — Injuries  to  Cranial  Nerves— Wounds  of  Brain  Substance — 
Hernia  Cerebri — Wounds  during  Birth — Bandaging  the  Head — Trephining — Indi- 
cations for  the  Operation — Operative  Technique — Excision  of  Irregular  Frag- 
ments —  Wounds  of  Eye  —  Wounds  of  Internal  Ear  —  Waunds  of  the  Face  —  Wounds 
of  the  Mouth. 

ANATOMICAL   CONSIDERATIONS. 

THERE  are  many  points  in  the  anatomy  of  the  skull  which  are  of  paramount 
importance  in  considering  the  nature  and  occurrence  of  wounds  of  its  com- 
ponent bony  parts  and  of  injuries  to  the  substance  of  the  brain  ;  but  those 
especially  concerning  us  when  considering  the  treatment  of  these  lesions 
are  comparatively  few,  and  can  be  covered  in  a  few  words.  The  perios- 
teum of  the  cranium — usually  called  the  pericranium — is  thin  but  quite 
strong  and  resistant.  Except  over  the  sutures  and  at  the  great  foramina  it 
can  be  easily  stripped  off,  or  even  made  to  glide  over  the  bone.  In  old 
people  its  connection  with  the  bone  is  more  firm.  It  is  nourished  princi- 
pally by  vessels  from  the  bone.  Concerning  the  bones  themselves  it 
should  be  remembered  that  the  diploii  is  wanting  both  in  young  as  in 
advanced  life. 

Of  great  importance  are  the  connections  which  the  veins  of  the  super- 
ficial soft  parts  enjoy  with  the  sinuses  of  the  bony  cavity  and  the  veins  of 
the  diploe  through  the  emissoria  Santorini.  The  most  important  of  these 
anastomoses  are  :  1.  Among  the  occipital  veins,  which  connect  through  the 
mastoid  foramen  with  the  lateral  sinus.  2.  Along  and  around  the  inter- 


302  THE    TREATMENT    OF    WOUNDS. 

parietal  suture,  especially  its  posterior  extremity,  where  numerous  open- 
ings connect  with  the  superior  longitudinal  sinus.  3.  The  ophthalmic 
veins,  according  to  Sesemann's  investigations,  empty  as  well  into  the  ca- 
vernous sinus  as  into  the  facial  veins.  By  this  it  will  be  seen  that  the 
sinuses  of  the  brain  have  their  overflow  outlets,  or  "  waste  weirs,"  in  what 
would  seem  to  be  abundance.  On  the  other  hand,  this  freedom  of  venous 
connection  enhances  the  danger  from  pysemic  or  thrombotic  trouble  in 
cases  of  erysipelas  or  phlegmon  of  the  external  soft  parts. 

SUPERFICIAL   WOUNDS  OF   THE  SCALP. 

It  will  be  well  at  the  very  outset  of  our  consideration  of  this  subject  to 
give  the  greatest  possible  prominence  to  the  classical  dictum,  "  No  injury 
of  the  head  is  too  slight  to  be  despised,  nor  too  severe  to  be  despaired  of ;'' 
a  statement  only  strengthened  by  time  and  experience.  The  temptation 
is  very  great  to  ignore  trivial  wounds,  to  insufficiently  cleanse  them,  to 
carelessly  dress  them.  If  nothing  else  teaches  the  danger  of  carelessness 
in  these  cases  the  experience  gathered  from  the  sword  duels  of  German 
students  should  be  convincing,  since  each  year  several  deaths  are  caused  by 
apparently  trivial  or  commonplace  wounds. 

We  may  divide  injuries  to  the  scalp  and  adjoining  soft  parts  into 
bruises  and  contusions,  penetrating  or  incised  wounds,  and  extensive  lac- 
erations, and  discuss  their  treatment  accordingly. 

BRUISES  AND  CONTUSIONS. — A  mild  bruise  or  contusion,  which  may  have 
caused  some  abrasion,  but  no  other  solution  of  continuity  nor  any  harm  to 
bone,  may  be  dressed  with  ordinary  evaporating  lotions,  or  cold  applica- 
tions either  in  bladders  or  ice-bags,  or  by  compresses  frequently  wet  in 
cold  water.  If  there  be  any  superficial  abrasion  some  antiseptic  should  be 
used,  a  little  alcohol  or  some  tincture  (e.g.,  tr.  arnica  or  spts.  camph.),  or 
carbolic  acid  or  iodoform.  Any  ordinary  effusion  of  blood  between  scalp 
and  bone  will  be  checked  and  then  rapidly  reabsorbed  under  this  treat- 
ment. The  hair  may  be  cut  short,  or  shaved  if  occasion  require.  If  effu- 
sion be  very  great,  and  apparently  not  checked  after  prolonged  trial  with 
simpler  measures,  then  it  may  be  well  by  free  incision  to  turn  out  the  more 
or  less  fluid  blood,  search  for  bleeding  vessels,  twist  or  tie  them  with  cat- 
gut,  cleanse  thoroughly,  wait  until  all  bleeding  has  stopped,  and  then 
neatly  approximate  the  edges  of  the  wound  with  fine  silk  or  catgut,  with 
the  insertion  of  a  few  threads  of  horse-hair  for  drainage,  and  over  all  a  firm 


WOUNDS    OF   THE   SCALP.  303 

compress.  Of  course  all  this  should  be  done  with  antiseptic  precautions, 
meaning  thereby  irrigation  with  carbolized  water,  clean  instruments  and 
sponges,  and  dressing  with  some  absorbent  antiseptic  material  (Chapter 
X.).  Best  and  avoidance  of  exposure  must  then  be  enjoined. 

PONCTUKED  OR  INCISED  WOUNDS. — A  small  punctured  wound,  as  made  by 
some  sharp  instrument,  should  be  treated  by  careful  cleansing  and  then  by 
antiseptic  occlusion,  as  with  borated,  salicylated,  or  iodoform  cotton.  A 
small  knife-blade,  the  point  of  a  foil,  or  other  pointed  instrument  may 
pierce  the  soft  parts  over  the  course  of  some  vessel,  and  without  doing 
material  injury  to  the  bone  sever  or  wound  an  artery  or  vein.  Several 
cases  of  aneurism  of  terminal  vessels  have  been  reported  as  occurring  in 
this  way.  From  such  a  wound  haemorrhage  would  be  free,  while  it  would 
be  easy  to  recognize  whether  an  artery  or  vein,  or  both,  had  been  injured. 
If  a  vein,  pressure  will  in  most  cases  be  sufficient ;  this  pressure  should  be 
made  a  part  of  the  antiseptic  occlusion,  being  maintained  by  an  elastic 
bandage  or  some  mechanical  device,  as  by  including  in  the  bandage  a 
piece  of  compressed  sponge  which  shall  later  be  moistened  with  carbolized 
water. 

But  if  an  artery  be  wounded  and  such  pressure  be  insufficient,  the  next 
measure  should  be  the  introduction  of  a  needle  threaded  with  silk,  which 
should  be  passed,  close  to  the  wound,  under  the  vessel  and  then  out ;  the 
thread  can  then  be  tied  in  a  simple  knot  or  over  a  compress  tight  enough 
to  constrict  the  same.  A  hare-lip  pin  or  even  a  common  pin  may  be  used 
instead,  a  thread  being  tightly  twisted  over  it  in  a  figure  of  eight.  If  this 
measure  be  required  it  should  be  done  on  either  side  the  cut,  which  should 
be  then  cleaned  and  occluded  as  before.  Or,  if  required,  the  wound  may 
be  freely  extended  with  a  scalpel,  the  hair  having  been  removed,  and  then 
the  bleeding  vessel  caught  and  secured.  After  this  careful  cleansing,  ap- 
proximation and  occlusion  as  before. 

EXTENSIVE  LACERATIONS. — Extensive  lacerated  or  complicated  incised 
wounds  are  often  inflicted,  by  accident  or  through  homicidal  intent,  which 
may  even  strip  the  pericranium  off  the  bone,  yet  without  causing  any  more 
dangerous  symptoms  than  a  temporary  concussion  or  "stunning."  In 
these  cases,  after  having  satisfied  himself  that  no  fracture  of  the  bone  has 
occurred,  at  least  none  calling  for  operative  procedure,  the  surgeon  should 
first  attend  to  every  oozing  point  or  spurting  vessel,  and  clip  short  the 
hair  about  the  region  of  the  wound.  He  should  then,  with  sponge  and 
forceps,  address  himself  to  the  removal  of  every  particle  of  dirt  and  every 


304  THE   TREATMENT   OF   WOUNDS. 

loose  hair.  Any  shred  of  tissue  about  whose  vitality  there  is  the  least 
doubt  had  better  be  clipped  off  All  bleeding  being  checked  it  remains 
now  to  close  the  wound  ;  but  one  cannot  be  too  careful  to  convince  him- 
self that  every  speck  of  dust  is  removed.  If  now  the  pericranium  have 
been  stripped  up,  its  edges  may  be  approximated  with  fine  catgut  Or  if 
its  edges  closely  correspond  with  those  of  the  scalp,  they  may  all  be  in- 
cluded in  one  stitching.  It  is  well  to  omit  a  stitch  at  each  angle  or  end  of 
the  wounds  to  allow  for  escape  of  pus,  should  any  form ;  though  if  all 
these  precautions  have  been  observed  one  may  expect  union  per  pi-imam  in- 
tentionem. 

Bather  fine  silk  is  perhaps  the  best  material  for  these  sutures ;  it  may 
either  be  carbolized  or  prepared  with  a  carbolized  wax,  which  makes  it 
stronger.  Stitches  should  not  be  more  than  a  quarter-inch  apart,  and  may 
be  either  continuous  or  interrupted,  according  to  the  fancy  of  the  surgeon ; 
excellent  results  may  be  achieved  with  either.  If  drainage  seem  to  be  indi- 
cated, it  may  be  accomplished  by  a  few  horse-hairs,  or  a  bundle  of  two  or 
three  silk  or  catgut  threads,  laid  especially  in  those  angles  of  the  wound 
which  are  to  be  dependent  It  has  been  suggested  to  use  the  natural  hairs 
of  the  part  for  the  approximation  of  the  lips  of  an  incised  wound  of  the 
scalp ;  but  it  is  difficult  to  make  a  knot  tied  with  hair  hold  firmly  enough 
to  answer  the  purpose.  Still,  it  may  be  tried  in  trivial  cases;  in  more 
severe  ones  it  is  hardly  to  be  adopted. 

The  wound  being  neatly  closed,  an  excellent  dressing  is  the  following": 
A  narrow  strip  of  protective,  moistened  with  a  solution  of  corrosive  subli- 
mate, 1  to  500,  is  first  laid  over  the  wound ;  then  a  few  layers  of  gauze, 
preferably  naphthalin  gauze  (for  reasons  elsewhere  stated,  vide  p.  305) ; 
then  a  layer  of  borated  or  salicylated  cotton  to  give  elasticity  to  the  com- 
press ;  then  a  few  larger  pieces  of  gauze,  a  piece  of  macintosh,  gutta-percha 
paper  or  waxed  paper,  and  over  all  a  roller  bandage  so  applied  as  to  make 
adequate  pressure.  The  writer  prefers  the  protective  slip  applied  imme- 
diately over  the  line  of  the  wound,  because  it  does  not  permit  dressings  to 
dry  and  stick  to  the  wound  or  to  the  ends  of  stitches,  and  thus  permits 
change  of  dressings  without  discomfort  to  the  patient. 

This  dressing  need  not  be  changed  for  from  two  to  six  days ;  earlier,  if 
provision  have  been  made  for  drainage ;  later,  if  not  If  thought  best  an 
ice-bag  may  be  applied  outside  of  its  masa 

In  those  cases  which  occasionally  occur  where  some  part,  or  nearly  the 
whole,  of  the  scalp  has  been  torn  of,  or  loose,  as  by  machinery  or  "  scalp- 


ERYSIPELAS    OF    THE   SCALP.  305 

ing,"  if  the  patient  be  seen  in  time,  an  effort  should  be  made  to  replace  the 
loose  portion.  Some  astonishing  successes  in  these  cases  have  been  re- 
ported, and  at  least  no  harm  is  done  if  the  trial  fail  The  general  rules 
already  given  are  sufficient  to  guide  the  reparative  effort ;  accurate  approxi- 
mation and  judicious  pressure  being  the  important  canons  of  treatment 
along  with  careful  antisepsis.  Should  the  effort  partially  succeed  or  fail, 
if  the  loss  of  substance  be  small,  a  plastic  operation  may  be  attempted ; 
otherwise  the  bare  or  raw  surface  must  be  kept  clean,  healthy  granulations 
stimulated  by  some  such  application  as  amorphous  boracic  acid,  and, 
when  attained,  the  healing  process  still  further  assisted  by  skin  grafting, 
or  the  newer  "sponge  grafting."  The  sponge  may  be  applied  in  fine  flecks, 
or  in  larger  but  very  thin  slices.  No  case  of  this  kind  which  is  not  speed- 
ily and  primarily  fatal  need  be  despaired  of. 

The  possibility  of  occurrence  of  erysipelas  in  all  these  cases  should  be 
borne  in  mind,  and  for  that  reason  additional  attention  should  be  paid  to 
enforcing  perfect  rest,  and  this  by  sedatives,  when  necessary,  as  during  an 
attack  of  delirium  tremens,  and  to  securing  a  soluble  condition  of  the 
bowels,  combating  fever,  keeping  up  the  strength,  etc!  Any  reasonable 
medicinal  means  for  attaining  any  or  all  of  these  conditions  are  justifiable. 
Moreover,  the  use  of  naphthalin,  in  gauze  or  in  fine  powder,  as  a  local  anti- 
septic, is  recommended,  especially  because  of  the  peculiar  properties  which 
it  seems  to  possess  as  opposed  to,  or  preventing,  erysipelaa 

It  may  happen  that  we  have  a  case  to  deal  with  which  has  already  be- 
come inflamed,  or  perhaps  erysipelatous,  either  through  bad  attention  or 
lack  of  any.  We  should  then  proceed  as  follows:  The  region  of  the 
wound  should  be  carefully  shaved,  or  the  hair  clipped  short  as  possible. 
If  the  appearance  of  the  part,  or  the  general  condition  of  the  patient,  indi- 
cate any  septic  process,  the  wound  should  be  opened,  and  its  interior 
freely  exposed  to  view,  while  a  most  painstaking  disinfection  of  its  entire 
surface  should  be  made.  Suppurating  or  foul  spots  or  surfaces  may  be 
treated  with  an  eight  per  cent  solution  of  zinc  chloride,  or  with  strong 
carbolic  acid,  new  openings  made  for  drainage  in  most  dependent  parts, 
and,  according  to  circumstances,  the  edges  reunited,  the  whole  left  more 
or  less  open  and  drained,  or  putrefying  and  necrosed  tissue  removed  with 
knife,  scissors,  or  curette.  Instead  of  the  zinc  chloride,  or  after  it,  an 
ethereal  solution  of  iodoform  or  naphthalin  may  be  used.  Abscesses 
should  be  freely  laid  open,  and  their  cavities  scraped  out  if  necessary.  If 
erysipelas  have  supervened,  the  whole  scalp  may  be  covered  with  antiseptic 
20 


306  THE    TREATMENT    OF    WOUNDS. 

poultices ;  it  may  be  kept  well  smeared  with  a  fifteen  to  twenty  per  cent, 
ointment  of  naphthalin,  or  the  old-fashioned  treatment  of  white-lead  paint, 
rubbed  up  with  a  little  turpentine,  may  be  resorted  to.  (It  will  be  remem- 
bered that  turpentine  is  a  very  fair  antiseptic.)  Few  surgeons  would  feel 
justified  in  making  ice  applications  to  an  erysipelatous  scalp,  unless  cere- 
bral complications  were  extremely  severe.  Of  course,  when  we  bear  in 
mind  the  anatomical  connection  of  the  scalp  and  deeper  parts  (vide  first 
paragraph  of  this  chapter),  it  will  be  understood  that  all  attacks  of  erysi- 
pelas about  the  scalp  are  at  least  serious. 

When  called  to  treat  the  later  results  of  former  injuries  in  the  line  of 
granulating  or  sluggish  ulcers,  or  exposed  and  carious  or  necrotic  bone, 
there  are  no  indications  in  their  case  calling  for  different  treatment  than 
similar  conditions  elsewhere  on  the  body.  A  healthy  ulcer  may  be  covered 
by  skin  or  sponge  grafts,  or  by  a  plastic  operation ;  an  unhealthy  one  should 
be  first  rendered  healthy,  and  this  best,  perhaps,  by  aid  of  boracic  acid  and 
an  occasional  stimulating  with  caustic.  All  dead  or  dying  bone  should 
be  removed  with  curette  or  chisel,  and  the  surface  then  allowed  to  heal  by 
granulation,  or  covered  by  a  plastic  operation,  or  both. 

SUPERFICIAL  GUN-SHOT  WOUNDS  should  be  treated  on  the  general  princi- 
ples above  enunciated ;  but  it  must  be  remembered  that  a  bullet  may  not 
only  pursue  a  devious  and  tortuous  path,  but  may  carry  in  foreign  matter. 
Such  a  wound  should  either  receive  primary  antiseptic  occlusion  (p.  248), 
or  its  track  be  carefully  cleansed  and  drained,  being  laid  open  for  this 
purpose  if  necessary ;  after  thorough  disinfection  it  does  not  differ  from 
any  other  wound  of  the  scalp,  so  far  as  indications  are  concerned.  Bullets 
may  be  left  until  a  subsequent  convenient  time  for  their  extraction,  or  they 
may  be  searched  out  at  once  and  removed,  with  due  antiseptic  precautions. 

DEEP  WOUNDS  OF  SCALP,   WITH  INJURIES  TO  THE  CRANIUM. 

Those  in  ivhich  there  are  no  Signs  of  Compression,— The  first  proce- 
dures in  these  cases  are  not  different  from  those  already  mentioned.  An 
antiseptic  cleansing  of  external  surfaces,  and  a  removal  of  hair  in  the 
neighborhood  of  the  lesion,  are  first  to  be  effected.  Next  should  follow  a 
checking  of  all  haemorrhage,  as  before  described.  Then  a  careful  examina- 
tion of  the  wound  should  be  made.  Should  it  appear  that  a  small  exter- 
nal wound  conceals  more  extensive  injury  or  laceration  beneath,  then  free 
incision  should  be  made  in  order  to  expose  every  part  to  sight  or  touch. 


INJURIES    TO    CRANIUM.  307 

According  to  the  extent  of  these  deeper  lesions  should  the  superficial 
wound,  as  now  extended,  be  reunited  or  noi 

It  may  happen  that  one  or  more  pieces  of  the  external  table  may  be 
entirely  separated  from  their  bony  surroundings,  and  held  only,  by  their 
connections  with  the  periosteum  and  soft  parts.  Not  forgetting  that  they 
may  be  still  nourished  by  these  connections,  it  is,  on  the  whole,  the  safest 
plan  to  remove  them.  But  should  a  prominent  process  of  bone  be  thus 
detached  from  its  seat — as,  for  instance,  a  part  of  the  supra-orbital  ridge,  or 
margin  of  the  orbit,  or  even  the  mastoid  process ' — it  would  only  be  good 
practice  to  make  every  endeavor  to  save  it.  Such  a  fragment  may  be  held 
in  place  possibly  by  pressure,  by  stitching  together  edges  of  periosteum, 
or  by  drilling  and  inserting  catgut  suturea  But  pieces  of  bone  that  lie 
entirely  loose  must  be  unhesitatingly  removed,  even  if  the  dura  mater  or 
brain  be  thereby  exposed. 

Should  haemorrhage  from  a  denuded  external  surface  of  bone,  or  oozing 
from  the  deeper  portion  occur  and  delay  the  surgeon,  it  may  be  checked 
by  irrigation  or  sponging  either  with  ice-water  or  water  as  hot  as  can  be 
borne  ;  preferably  the  latter.  After  it  has  been  once  fully  checked  it  is 
not  likely  to  recur  after  the  parts  are  closed  in  from  the  air,  as  when  the 
dressing  with  suitable  compression  has  been  made. 

Aside  from  leaden  projectiles  a  variety  of  foreign  bodies  may  not  only 
injure  the  cranial  bones,  but  parts  of  them  may  even  be  embedded  ;  work- 
men's pointed  tools,  knife-blades,  bayonets,  sword  or  foil  points,  arrow- 
heads, hatchet  or  tomahawk  points,  pieces  of  glass,  etc.  In  pi-oportion  as 
these  penetrate  deeper,  the  gravity  of  the  wound  and  the  possibility  of  de- 
pression or  perforation  of  the  inner  table  are  greater ;  but  the  indications 
do  not  differ  greatly  so  far  as  the  therapeutic  measures  are  concerned. 
Obviously  their  removal  is  called  for,  in  most  cases  at  least,  and  this  should 
be  accomplished  with  the  least  possible  disturbance.  If  a  simple  pull  be 
insufficient,  enlargement  of  the  external  wound  and  instrumental  aid  must 
be  resorted  to.  Strong  forceps,  a  pointed  elevatorium,  a  removal  of  sur- 
rounding bone  by  means  of  chisel  or  gouge,  and  possibly  even  the  trephine, 
may  in  succession  be  called  for.  The  more  recent  the  case  the  better,  as  a 
rule,  the  results.  If  any  pointed  instrument  should  evidently  have  pene- 
trated the  cranium,  it  should  be  removed  by  the  most  direct  pull  in  the 
direction  of  the  line  of  its  entrance,  so  that  farther  injury  to  brain  tissue 

1  BouUet,  These  de  Paris,  1878.  Dupuytren,  Lemons  orales,  t.  i.,  p.  58.  Berymann. 
Kopfverletzungen,  p.  252. 


308  THE    TREATMENT    OF    WOUNDS. 

or  coverings  may  be  avoided.  As  more  or  less  haemorrhage  may  take 
place  from  the  wound  in  the  tables  of  the  skull  immediately  after  removal 
of  the  body,  especially  if  it  have  penetrated,  absorbent  cotton  should  be 
plugged  into  the  wound,  or  the  head  at  least  placed  in  such  a  position  that 
bleeding  into  the  cavity  of  the  cranium  may  not  take  place. 

In  every  case  where  solution  of  continuity  of  the  outer  table  has  oc- 
curred, the  surgeon  should  bear  in  mind  what  a  vantage  ground  the  diploii 
offers  for  the  lodgement  of  septic  germs  and  for  the  development  of  in- 
flammatory and  septic  thrombotic  processes  which  may  greatly  militate 
against  the  safety  of  the  patient ;  and  he  should  in  such  cases  omit  no  pre- 
caution which  may  tend  to  avert  their  destructive  agency.  Rigid  antisep- 
sis, or  preferably,  if  it  can  be  put  into  practice,  rigid  asepsis  must  be  the 
motto;  without  it  no  such  wound  can  be  properly  treated.  To  quote 
Bergmann  (L  c.,  p.  83).  "We  have  learned  to  appreciate  that  every  wound, 
every  contusion  of  the  head  fares  better  in  the  poorest  private  dwelling 
than  in  the  richest  hospital.  And  if  this  protection  [antisepsis]  is  indi- 
cated in  private  practice,  it  certainly  does  not  come  amiss  in  the  worst 
hospital" 

If  instead  of  finding  some  portion  of  bone  chipped  off,  or  some  foreign 
body  embedded  or  loose,  we  find  simply  lines  of  cleavage  indicating  linear 
fracture,  different  lines  of  treatment  should  be  pursued,  according  to  what 
we  judge  the  character  and  extent  of  the  fracture  to  be.  If  symptoms 
of  compression  indicate  protrusion  inward  of  some  bony  fragment  of  the 
inner  table,  the  trephine  is  called  for,  as  will  be  subsequently  considered 
when  discussing  the  indications  for  trephining.  If,  on  the  other  hand,  no 
sign  of  intra-cranial  trouble  be  manifest,  and  no  loose  piece  of  bone  demand 
removal,  the  case  should  be  treated  much  as  if  no  such  serious  lesion  were 
present,  save  that  the  antisepsis  should  be  rigid,  and  absolute  and  pro- 
longed rest  be  insisted  upon. 

It  will  be  as  appropriate  here  as  anywhere  to  discuss  the  treatment  of 
any  severe  contusion  of  the  skull,  which  from  the  history  of  the  injury  or 
the  inherent  features  of  the  case  has  in  all  probability  produced  some 
fracture  of  the  cranial  vault.  Such  a  fracture  is  to  be  considered  from  the 
same  point  of  view  as  a  simple  fracture  of  any  bone,  deriving  special  im- 
portance only  when  there  is  concomitant  or  subsequent  injury  to  the 
cranial  contents.  Notwithstanding  the  internal  table  is  often  very  exten- 
sively injured,  many  cases  of  simple  depressed  fracture  proceed  to  per- 
manent recovery  without  any  active  treatment  and  without  alarming  head- 


SIMPLE    FRACTURES    OF    SKULL.  309 

symptoms  at  any  time  in  their  course.  In  all  cases  of  simple  fracture, 
whatever  the  depression,  or  however  great  the  comminution  of  the  bone,  a 
conservative  line  of  treatment  should  be  adopted,  and  the  simple  fracture 
converted  into  a  compound  one  by  incision  of  the  soft  parts  covering  it,  for 
the  purpose  of  the  application  of  a  trephine  or  the  removal  of  detached 
splinters  of  bone,  only  when  prolonged  or  alarming  symptoms  of  intra- 
cranial  mischief  render  it  imperative.  As  to  the  conditions  in  which  imme- 
diate resort  to  the  trephine,  in  cases  of  simple  fracture,  is  imperative,  in 
the  opinion  of  Sands,  of  New  York,  there  are  but  two,  of  which  he  speaks 
as  follows : l 

"  One  of  these  is  the  case  in  which  the  fracture  is  of  limited  extent,  and 
in  which  there  is  reason  to  think,  from  its  situation,  or  from  the  occurrence 
of  monoplegia,  monospasm,  or  hemiplegia,  that  a  splinter  from  the  inner 
table  may  have  penetrated  the  motor  tract  of  the  cerebral  cortex.  But,  as 
we  have  seen,  the  fractures  which  are  attended  with  such  displacement  of 
fragments  of  the  inner  table  are  usually  of  small  extent,  and  are  almost  in- 
variably compound.  The  other  case  is  the  one  in  which  compression  of 
the  brain  is  caused  by  an  accumulation  of  blood  between  the  dura  mater 
and  the  cranium.  Such  an  accumulation  may  result  from  a  wound  of  one 
of  the  larger  venous  sinuses,  but  in  a  large  majority  of  instances  it  depends 
on  a  wound  or  a  laceration  of  the  middle  meningeal  artery.  The  accident 
is  most  frequently  accompanied  by  a  compound  fracture ;  but  it  may  be 
met  with  in  cases  of  simple  fracture,  and  occasionally  when  no  fracture  is 
present.  When  there  exists  a  compound  fracture,  the  blood  usually  escapes 
through  the  external  wound,  thus  rendering  the  diagnosis  easy  ;  but  when 
the  fracture  is  simple,  or  when  the  artery  alone  is  injured,  the  extravasated 
blood  separates  the  dura  mater  from  the  cranium,  and  may  be  poured  out 
in  sufficient  quantity  to  cause  fatal  compression  of  the  brain.  The  amount 
of  blood  thus  extravasated  may  be  as  much  as  half  a  pint.  When  the 
brain  has  not  sustained  severe  injury,  and  the  symptoms  of  concussion  may 
be  but  slight,  the  signs  of  the  arterial  lesion  may  be  quite  characteristic. 
After  a  blow  has  been  received,  usually  in  the  temporo-parietal  region,  the 
patient,  although  perhaps  slightly  stunned,  soon  regains  consciousness,  and 
exhibits  no  marked  signs  of  cerebral  injury.  But  after  the  lapse  of  a  few 
minutes,  or  possibly  several  hours,  symptoms  of  compression  appear,  and 

1  The  Question  of  Trephining  in  Injuries  of  the  Head.  Annals  of  Anatomy  and 
Surgery,  1883,  viii.,  p.  99. 


310  THE    TREATMENT    OF    WOUNDS. 

soon  become  very  marked,  the  patient  often  dying  within  twenty-four  hours 
from  the  time  of  the  accident.  Hemiplegia  sometimes  occurs  before  insen- 
sibility is  complete ;  and  its  detection  is  important,  for  the  reason  that  a 
blow  upon  one  side  of  the  head  has  been  known  to  cause  a  rupture  of  the 
artery  on  the  opposite  side.  The  accident  affords  a  clear  and  positive  in- 
dication for  the  application  of  the  trephine  ;  yet  there  are  but  few  recorded 
cases  of  the  operation." 

Should  destruction  of  soft  parts  be  so  extreme,  should  laceration  be  so 
'  extensive,  that  it  seems  best  to  remove  more  or  less  tissue,  fearing  that  its 
vitality  is  lost,  the  surgeon  need  not  hesitate  to  make  a  plastic  operation  to 
cover  the  defect,  provided  it  seem  advisable.  And  even  if  the  bone  have 
been  denuded,  nay,  even  if  the  dura  mater  be  laid  bare,  as  will  happen 
after  certain  injuries  as  well  as  operative  procedures,  unless  something  else 
:  centra-indicate  it,  plastic  operations  may  still  be  made.  The  writer  has 
repeatedly  succeeded — like  every  surgeon  who  has  tried  it — in  making 
skin  flaps  adhere,  per  primam  intentionem,  to  rjortions  of  the  cranial  vault 
whose  external  table  had  been  removed ;  while  surgical  literature  contains 
abundant  reference,  which  coincides  with  personal  experience,  to  cases  in 
which  they  have  adhered  equally  well  to  the  dura  mater. 

In  case  of  a  short  fissure  or  circumscribed  depression  of  the  outer  table 
the  surgeon  has  but  little  to  do  beyond  careful  dressing,  and  may  almost 
limit  his  use  of  instruments  to  the  needle. 

Should  a  sequestrum  exist  underneath  a  granulating  mass,  as  may  re- 
sult during  the  course  of  some  of  these  cases,  it  should  be  removed  like  a 
similar  foreign  mass  elsewhere  in  the  body. 

Wounds  are  occasionally  inflicted  with  saws,  as  in  the  following  case  re- 
lated to  the  writer.  A  laborer  in  a  saw-mill  fell  in  such  a  way  that  his 
head  was  thrown  up  against  a  saw  in  rapid  motion.  A  clean  cut  was  made 
through  scalp,  skull,  and  an  uncertain  distance  into  the  brain ;  the  line 
being  along  to  one  side  of  the  superior  longitudinal  sinus.  The  man  was 
•at  once  removed  to  his  home  and  medical  aid  summoned  ;  but  there  was 
very  little  to  do  and  he  was  treated  symptomatically. 

Considerable  discussion  arose  as  to  what  extent  it  would  be  proper  to 
sew  up  the  external  wound,  etc.,  and  the  home  talent  finding  this  too 
knotty  a  problem  to  decide  called  counsel  from  a  neighboring  large  city. 
But  while  the  surgeons  were  discussing  the  pros  and  cons  of  this  question 
the  patient  progressed  rapidly,  and  by  the  time  the  matter  was  finally 
settled  he  was  evidently  out  of  danger. 


SIMPLE    FRACTURE    OF    SKULL.  311 

Should  the  reader  meet  such  a  case,  his  best  policy  would  be  to  ab- 
stain from  any  active  interference,  to  shave  the  parts,  to  approximate  the 
edges  of  the  scalp  wound,  save  at  certain  points  for  drainage,  to  use  anti- 
septics and  probably  ice  applications.  If  any  serious  haemorrhage  were  in 
progress  the  case  would  fall  under  the  head  of  injuries  to  the  vessels  and 
sinuses  of  the  cranium,  to  be  considered  in  another  paragraph. 

The  gunshot  wounds  made  by  modern  projectiles  are  noted  for  the 
numerous  splinters  around  the  edge  of  the  lesion  they  cause.  These  splin- 
ters being  loose  or  almost  so,  should  be  carefully  removed. 

It  should  not  be  forgotten  that  children  have  no  frontal  sinus,  and 
that  consequently  the  brain  lies  close  to  the  front.  Hence  a  fracture 
of  the  os  frontis  in  children  should  not  be  indifferently  probed,  nor  even 
such  an  examination  made  as  may  sometimes  be  permitted  in  an  adult, 
nor  need  it  cause  surprise  if  the  dura  mater  seem  very  close  to  the 
surface. 

Fistulous  openings  may  remain  long  after  injuries  such  as  we  have 
been  considering  have  apparently  or  for  the  most  part  healed.  Their 
treatment  is  the  conventional  one,  i.e.,  free  exploration  with  removal  of  all 
tuberculous  debris  or  diseased  bone. 

Fractures  of  the  Base  of  the  Skull,  and  Diastasis  of  Sutures. — It  happens 
rarely  that  cases  of  fracture  of  the  base  of  the  skull  which  are  really  amenable 
to  treatment  come  under  the  surgeon's  care.  Too  many  of  these  cases  are 
either  dead  by  the  time  of  the  surgeon's  visit,  or  are  past  help  and  die  un- 
conscious. Nevertheless  cases  which  there  is  every  reason  to  diagnose  as 
fractures  of  the  base  do  once  in  a  while  recover,  and  it  should  always  be 
the  rule  to  treat  even  the  most  desperate  case  as  if  there  were  at  least  a 
possibility  that  appearances  would  prove  deceptive. 

If  there  be  bleeding  from  the  nose  it  would  be  well  to  use  a  douche  of 
some  kind,  either  quite  cold  or  quite  warm  water,  which  should  be  iodin- 
ized.  The  styptic  effect  of  hot  water  in  epistaxis  is  as  well  known  as  is 
its  power  over  haemorrhage  elsewhere,  and  it  should  be  made  use  of  in 
these  cases. 

Bleeding  or  serous  oozing  from  the  ear  should  be  treated  similarly  with 
quite  warm  iodinized  water,  and  after  the  injection  the  meatus  should 
be  filled  with  boracic  acid  in  amorphous  powder,  or  a  little  iodoform 
should  be  blown  in,  and  then  a  plug  of  antiseptic  cotton  inserted  ;  all  this 
to  be  repeated  as  often  as  may  be  needed. 

Any  injury  of  soft  parts  or  cranial  vault  that  may  be  discovered  should 


312  THE    TREATMENT   OF    WOUNDS. 

be  treated  in  accordance  with  those  rules  already  laid  down  at  sufficient 
length. 

The  balance  of  the  treatment  must  be  symptomatic  and  largely  medici- 
nal If  collapse  be  imminent,  local  and  general  stimulation  in  moderation, 
not  to  excess,  lest  with  vigorous  reaction  come  undesirable  consequences. 
If  the  heart's  action  be  weak,  a  sponge  wrung  out  of  hot  water  and  sopped 
over  the  cardiac  region,  or  heat  and  cold  alternated,  with  hypodermics  of 
ether,  or  of  atropia  (^y  to  -fe  grain).  When  once  the  pulse  and  respiration 
are  satisfactory,  and  the  bowels  cleared  out,  the  rest  must  be  left  largely 
to  time.  Ice  applications  to  the  head  may  be  indicated — will  be,  in  fact,  if 
temperature  rises  or  meningitis  occur.  Artificial  nourishment  will  be  re- 
quired as  unconsciousness,  paresis,  or  paralysis  complicate  the  case.  This 
may  be  administered  by  the  long  tube  either  into  the  stomach  or  rectum, 
as  seems  best  in  each  case. 


TREATMENT  OF   COMPRESSION  OF   THE  BRAIN. 

Treatment  of  this  condition  cannot  be  separated  from  that  of  the  cause 
that  produces  it.  Obviously  the  first  measure  must  be,  after  cleansing  and 
exploration,  the  removal  of  the  compressing  fragment,  if  such  there  be. 
Next  may  be  considered  the  advisability  of  the  withdrawal  of  a  certain 
amount  of  blood,  either  by  venesection  or  arteriotomy,  for  the  sake  of 
weakening  the  heart's  action  and  diminishing  the  amount  of  blood  in  the 
system.  In  this  connection  one  should  take  into  consideration  the  result 
of  Althann's  investigations ;  he  found  that  after  bleeding,  even  though  its 
volume  was  reduced,  the  blood  could  better  pass  through  the  capillaries. 
Nevertheless,  remembering,  too,  that  patients  often  recover  quicker  from 
apoplectic  attacks  after  bleeding,  we  may  regard  venesection  as  a  proper 
measure,  at  least  when  pressure  or  congestive  symptoms  are  severe.  The 
return  of  blood  from  the  head  may  also  be  hastened,  and  its  access  hin- 
dered by  having  the  head  well  raised,  or  the  patient  in  an  only  partially  re- 
cumbent posture.  Saline  cathartics  are  indicated,  or  any  other  means 
which  shall  tend  to  drain  the  blood  of  its  serum,  and  so  compel  reab- 
sorption  of  the  effused  fluids.  Any  means  also  which  may  persuade  the 
arteries  to  contract,  i.e.,  vaso-motor  stimulants,  such  as  ergot  or  small  doses 
of  atropia,  may  be  useful  later.  To  the  same  end  the  constant  galvanic 
current  may  be  employed. 

Cold  applications  are  also  of  undoubted  but  rather  uncertain  value  in 


WOUNDS    OF    INTRA-CRANIAL    VESSELS.  313 

these  cases.  Pirogoff  has  recommended  a  continual  dropping  of  cold  water 
on  the  head,  or  something  like  a  very  mild  cold  douche  ;  others  also  have 
noticed  a  rapid  return  to  consciousness  after  this  had  been  tried.  The 
necessary  apparatus  for  this  purpose  may  be  easily  made  with  a  nasal 
douche  or  fountain  syringe.  When  they  are  at  hand  the  skull-cap  of 
leaden  tubes,  as  made  by  Leiter,  or  a  coil  of  rubber  tubing  supported  by  a 
wire  frame,  through  which  ice-water  shall  continually  flow,  will  be  found 
perhaps  equally  effective. 

So  much  of  the  operative  treatment  of  these  cases  as  has  not  already 
been  considered  will  fall  under  the  head  of  trephining,  to  be  dealt  with 
further  on. 

WOUNDS  OF  INTRA-CRANIAL  VESSELS  AND  SINUSES. 

These  wounds  most  often  involve  the  longitudinal  and  transverse  si- 
nuses and  the  middle  meningeal  artery.  It  occasionally  happens  that  these 
are  injured  during  the  operation  of  trephining,  but  these  are  by  no  means 
necessarily  fatal ;  in  fact,  in  more  than  one  case  the  effect  was  that  of  vene- 
section, and  was  good.  If  by  a  small  penetrating  wound  a  superficial  sinus 
be  punctured,  an  antiseptic  compress  may  be  sufficient  to  check  bleeding  ; 
over  this  an  ice-cold  application  should  be  made.  The  cases  are  numerous 
in  which  rapid  recovery  has  followed  this  simple  measure.  Death  is  in 
such  cases  unusual,  and  results  rather  from  other  complications,  such  as 
injury  to  the  brain,  or  partial  escape  of  blood  into  the  cranial  cavity,  or 
from  septic  processes.  Genzmer  '  has  related  a  fatal  case  from  Volkmann's 
clinic  of  entrance  of  air  into  a  sinus  during  extirpation  of  a  sarcoma  from 
the  bone  and  dura  mater.  But  under  most  conditions  this  would  never 
happen.  Wounds  of  the  cavernous  sinus  through  the  orbit  have  always 
been  fatal 

When  a  splinter  of  bone  or  a  foreign  body  has  perforated  a  sinus  wall 
the  blood  may  escape  at  once  or  only  after  its  removal.  These  cases  are 
rare.  The  hemorrhage  may  be  checked  by  tampons,  with  ice  applications, 
or  the  sinus  walls  may  be  sewed  together,  as  in  the  following  unique 
case  reported  by  Professor  C.  T.  Parkes,"  of  Chicago.  In  June,  1882, 
he  was  called  to  treat  a  man  who  had  received  a  compound  commi- 
nuted fracture  of  the  skull,  with  depression  ;  the  fractui-e  was  just  in  front 

1  VerJiandl.  d.  deutscfien  Gesdlschaft  f,  Chirurgie,  1877,  ii.,  32. 
1  Annals  of  Anatomy  and  Surgery,  1883,  viii.,  118. 


314  THE    TREATMENT    OF    WOUNDS. 

of  the  middle  of  the  sagittal  suture,  extending  into  and  involving  the  right 
parietal  bone.  The  depressed  portion  was  fully  an  inch  in  longest  diam- 
eter, and  extended  a  little  to  right  of  median  line.  He  had  paralysis  of  left 
side,  but  no  head  symptoms.  An  anaesthetic  having  been  given,  Professor 
Parkes  endeavored  to  remove  the  fragments.  After  removal  of  two  or  three 
a  terrific  haemorrhage  set  in,  so  that  he  was  compelled  to  occlude  the  open- 
ing by  a  pad  of  antiseptic  gauze.  Next  morning  he  removed  the  compress 
and  found  the  haemorrhage  to  at  once  recur.  As  rapidly  as  possible  he  re- 
moved the  fragments,  exposing  the  dura  mater,  when  he  found  a  large 
opening  in  the  upper  wall  of  the  longitudinal  sinus,  from  which  the  blood 
poured  in  a  stream.  He  packed  the  opening  with  sponge,  and,  clearing 
out  all  debris,  smoothed  off  the  roughened  edges  of  bone.  Finding  the 
dura  entire,  with  above  exception,  he  removed  the  sponge  and  united  the 
edges  of  the  rent  with  three  fine  catgut  sutures.  Bleeding  was  checked  at 
once,  and  the  man  made  an  excellent  recovery.  The  opening  in  the  sinus 
was  as  large  as  a  coffee-bean. 

These  wounds  of  sinuses  usually  heal  well,  with  only  a  thickening  of 
walls  ;  but  entire  obliteration  of  a  single  channel  is  of  no  great  import,  as 
Schellmann's  researches  '  have  shown.  The  principal  danger  comes  from 
softening  of  thrombi. 

Holmes,2  Gamgee,  and  Gross,8  along  with  others,  have  related  cases  of 
penetrating  wounds  which  have  injured  the  middle  meningeal  artery.  It 
has  several  times  happened  that  this  vessel  required  ligation  during  re- 
moval of  fragments  after  severe  injury ;  while  during  our  civil  war  the 
common  carotid  was  seven  times  ligated  for  this  same  purpose,  with  three 
recoveries.  When  gradually  increasing  symptoms  of  compression  lead  us 
to  fear  a  rupture  of  this  vessel,  although  there  be  no  open  wound,  the  pro- 
priety of  trephining  over  its  course  with  a  view  to  its  ligation  may  then  be 
discussed.  In  1839  Keate  removed  a  depressed  piece  of  bone  and  caught 
it  in  its  course  while  spurting.  Tatum,  Beck,  Hueter,  Physick,  Bird,  So- 
cin,  and  others  have  done  this  or  similar  operations  with  success.  Should 
such  a  measure  be  decided  upon,  the  coagula  should  be  as  far  as  possible 
removed,  and  everything  should  be  done  under  aseptic  precautions.  A 
case  of  Parker's  4  will  be  instructive  in  this  connection.  In  this  there  was 
no  external  wound  of  soft  parts  ;  nevertheless  he  trephined  over  the  artery 

1  Ueber  Verletzung  der  Hirnsinu*  ;  Diasertat.,  Giessen. 

5  Treatise  on  Surgery,  1875.  J  Am.  Jour.  Med   Sci.,  July,  1873. 

4  Med.  Times,  1877,  L,  p.  91. 


INTRA-CRANIAL   INJURIES.  315 

on  one  side,  but  found  no  lesion  ;  he  then  trephined  over  the  artery  on  the 
other  side,  but  found  no  coagulum  outside  the  dura  ;  but  since  the  latter 
had  a  distended  and  bluish  appearance  he  incised  it  and  removed  a  con- 
siderable amount  of  blood.  In  three  days  the  patient  became  conscious, 
and  then  quickly  recovered. 

Injuries  to  the  cerebral  portion  of  the  internal  carotid  are  much  rarer 
than  those  to  the  meningeaL  Longmore  relates  that  a  bullet  penetrated,  in 
one  case,  through  the  orbit  into  the  petrous  bone  and  lodged  there,  but 
led  to  erosion  of  this  trunk  and  fatal  haemorrhage.  Some  injury  of  this 
kind  might,  if  not  rapidly  fatal,  lead  to  the  formation  of  an  arterio-venous 
aneurism  calling  for  ligation  of  the  common  trunk. 

The  treatment  of  wounds  of  vessels  in  the  substance  of  the  brain  can- 
not differ  from  that  already  laid  down.  Could  haemorrhage  in  the  sub- 
dural  space  be  diagnosed,  it  would  be  good  practice  to  trephine  and  open 
the  dura.  One  such  case  was  reported  during  our  war  (vide  Gross,  1.  c.). 
"  There  are  100  cases  of  haemorrhage  from  the  middle  meningeal  artery 
known.  Of  these  17  recovered  ;  in  12  of  these  17  the  blood  escaped 
through  the  external  wound.  Of  the  remaining  5  one  recovered  without 
operation  ;  the  others  recovered  after  trephining  and  evacuating  the  blood 
through  the  opening.  In  Hueter's  case  the  bleeding  vessel  was  secured  by 
a  ligature  "  (Sands). 

INJURIES  TO  CRANIAL  NERVES. 

The  treatment  of  injuries  to  these  nerves  inside  the  cranium  cannot  be 
other  than  symptomatic.  Should  a  depressed  fragment  or  a  foreign  body 
press  upon  a  nerve-trunk,  removal  of  the  same  would  meet  the  principal 
indication,  and,  provided  the  injury  were  not  too  severe  in  other  respects, 
the  nerve  might  regain  more  or  less  of  its  function.  When  it  is  certain 
that  a  nerve-trunk  outside  the  cranium  is  severed,  it  would  be  good  prac- 
tice to  dissect  down  upon  it  and  unite  the  severed  ends  with  a  fine  carbo- 
lized  catgut  suture,  just  as  should  be  dene  elsewhere  in  the  body. 

WOUNDS  OF  BRAIN  SUBSTANCE. 

Inasmuch  as  these  are  inevitably  complicated  with  those  of  parts  ex- 
ternal, we  can  draw  no  abrupt  therapeutical  distinction.  Obviously,  if 
antiseptic  measures  are  indicated  for  more  superficial  injuries,  they  are 
vitally  essential  here.  "We  wish  to  emphasize,  also,  more  fully  in  this  con- 


316  THE   TREATMENT    OF    WOUNDS. 

nection,  what  has  already  received  mention  in  this  work,  and  that  is,  the 
futility — we  are  almost  tempted  to  say  the  homicidal  effect — of  careless  or 
ineffectual  probing  for  bullets,  since  most  of  these  wounds  are  made  by 
projectiles.  The  array  of  cases  set  forth  by  German  military  surgeons,  in 
which  most  dangerous  wounds,  such  as  when  treated  by  old  methods  of 
promiscuous  bullet-hunting,  were  surely  fatal,  primarily  and  antiseptically 
occluded,  and  never  probed  nor  investigated,  have  gone  on  to  speedy  re- 
covery— this  array  should  be  most  convincing  as  to  the  merits  of  this 
practice. ' 

Probing  disturbs  clots  and  all  reparative  effort,  and  too  often  introduces 
septic  germs  into  deep  parts.  Suppose  we  know  a  bullet  has  entered  a 
head,  and  are  able  to  follow  its  track  with  a  probe  two  inches  deep  into 
the  brain,  what  good  have  we  accomplished,  what  valuable  knowledge 
gained  ?  We  knew  that  it  had  penetrated  ;  we  could  have  made  a  guarded 
if  not  a  very  grave  prognosis  without  the  probing  ;  we  have  gained  noth- 
ing, but,  on  the  contrary,  may  have  introduced  new  and  disturbing  ele- 
menta  The  practice,  then,  which  will  commend  itself  is  the  following  : 

If,  after  a  gunshot  or  small  perforating  wound,  there  be  no  symptoms 
indicating  a  serious  haemorrhage  or  compression,  as  from  a  depressed 
fracture  calling  for  operation,  the  treatment  is  most  simple,  and  consists  of 
antiseptic  cleansing  and  occlusion  of  the  external  wound,  cold  applications 
to  the  head,  free  evacuation  of  the  bowels,  and  absolute  rest.  The  occlu- 
sion should  be  made  with  simple  iodoform  cotton,  or  something  of  the  kind. 
If,  after  the  lapse  of  hours,  symptoms  of  compression  or  intracranial  lesion 
supervene,  then  the  trephine  will  be  called  for.  When  once  decided  on, 
the  earlier  it  is  used  the  better,  and  of  course  with  all  antiseptic  precau- 
tions. If,  on  removal  of  the  disc  of  bone,  it  shall  appear  that  depression 
caused  the  trouble,  after  it  is  relieved  no  further  operation  is  needed.  If 
a  clot  be  found  between  dura  and  skull  it  should  be  carefully  removed,  if 
necessary  by  removal  of  other  buttons  of  bone.  If  a  pouting  and  dark 
appearance  of  the  dura  make  it  probable  that  there  is  subdural  haemor- 
rhage, an  incision  through  it  should  be  made,  and  blood  removed  as  before. 
If,  during  these  manipulations,  the  foreign  body  be  recognized,  it  would 
be  well  to  remove  it  as  gently  as  possible  ;  but  the  circumstances  must  be 
very  rare  which  shall  justify  random  exploration  in  the  brain  for  a  bullet 
Even  if  a  bullet  were  touched  at  the  depth  of  an  inch,  its  removal  would 
be  attended  by  risk  of  haemorrhage  such  as  might  be  difficult  to  master. 

1  Vide  Annals  of  Anatomy  and  Surgery,  1883,  vii.,  114. 


HERNIA    CEltEBRI.  317 

r 

Moreover,  many  recorded  cases  prove  with  what  apparent  freedom  from 
serious  consequences  patients  may  recover  with  such  foreign  masses  as 
bullets  in  their  brains.  Not  a  few  men  are  to-day  at  work,  who  are  known 
to  be  carrying  some  small  mass  of  lead  embedded  in  their  brains.  The 
safest  rule  to  follow,  then,  is  to  abstain  from  all  operative  measures  vihen 
the  indications  become  obscure. 

HERNIA  CEREBRI. 

When  from  a  recent  wound,  or  one  of  a  few  days  or  weeks'  standing, 
protrusion — hernia  cerebri — takes  place,  it  may  seem  doubtful  whether  it 
would  be  better  to  excise  the  protruding  mass  or  to  endeavor  to  replace  it 
by  suitable  pressure.  Of  course  the  careful  surgeon  will  dress  all  fresh 
cases  with  such  a  judicious  amount  of  pressure  as  shall  guard  against  this 
condition  ;  but  he  may  be  called  on  to  treat  it  after  it  has  happened.  If 
the  hernia!  mass  has  commenced  to  slough,  there  can  be  no  question  ;  ex- 
cision must  be  practised  and  haemorrhage  carefully  watched  for  and 
checked  ;  twisting  or  tying  any  little  spouting  vessel — pressure,  or  the 
not  too  hot  cautery  on  oozing  points,  •will  usually  govern  this.  When 
the  mass  appears  healthy,  gentle  but  continuous  pressure  will  usually 
cause  the  disappearance,  within  the  cranium,  of  its  proper  contents.  If 
this  cannot  be  accomplished  during  the  time  of  an  ordinary  dressing,  com- 
presses and  bandages  should  be  arranged  so  as  to  exert  an  unintermitting 
pressure.  After  reduction  a  lead  or  caoutchouc  plate  may  be  adapted  to 
the  shape  of  the  part  and  applied  externally  as  a  portion  of  the  bandage 
technique. 

Cauterizing  or  ligating  the  protruded  mass  is  almost  as  dangerous  as 
excising  it. 

If  an  abscess  underlie  it,  as  may  be  ascertained  by  the  hypodermic 
syringe  needle  when  suspected,  its  contents  should  of  course  be  evacuated. 

Adams  has  reported  a  case  of  irreducible  hernia  cerebri,  in  which  he 
succeeded  in  covering  the  hernial  mass  with  a  flap  of  skin  by  a  plastic 
operation,1  and  Kusmin  another  similar,  except  that  he  resorted  to  skin 
grafting.11 

1  Lancet,  1876,  No.  11. 

1  St.  Petersburg.  Med.  WocJuschft.,  1878,  No.  17. 


318  THE    TREATMENT    OF    WOUNDS. 

WOUNDS  DURING  BIETH. 

With  reference  to  those  injuries  to  the  foetal  head  which  may  happen 
during  natural  or  artificial  delivery,  it  is  necessary  to  add  but  little.  Even 
large  extravasations  of  blood  are  usually  absorbed  ;  in  extreme  cases, 
after  waiting  a  few  days,  it  might  be  well  to  incise  them  and  turn  out  the 
clots.  Excoriations  and  bruises  made  by  instruments  need  only  conven- 
tional treatment.  Fatal  phlegmonous  inflammation  has  been  known  to 
result  from  such  injury  done  by  forceps,  hence  the  necessity  for  antisepsis 
and  attention  to  detail  Symptoms  arising  from  the  compression  caused 
by  the  forceps  will  usually  subside  as  the  head  resumes  its  shape.  Should 
positive  fracture  take  place,  it  will  probably  run  its  course  uninfluenced  by 
therapeutic  measures.  Perfect  rest  and  cool  applications  will  constitute 
about  all  that  can  be  done.  The  prognosis  must  be  based  on  the  amount 
of  injury. 

BANDAGES   FOR   THE   HEAD. 

Apposition  of  wound-surfaces,  compression,  and  the  retention  of  dress- 
ings in  their  place  require  much  ingenuity  in  the  application  of  proper 


Via.  92.— Doable-headed  Boiler.  FIG.  93.— Sagittal  Bandage. 

bandages  in  the  case  of  head-injuries.  The  following  figures,  copied,  to- 
gether with  their  descriptions,  from  Esmarch's  "  Surgeon's  Handbook/' 
will  serve  to  indicate  those  methods  of  bandaging  most  likely  to  be  of 
service. 

The  double-headed  roller  (Fig.  92)   is  applied  by  placing  the  centre  of 
the  bandage  opposite  to  the  seat  of  injury,  and  carrying  the  two  heads  past 


BANDAGES    FOB   THE    HEAD. 


319 


each  other  with  gradually  increasing  traction  upon  the  wound  ;  these  turns 
are  then  brought  back  again  to  the  starting-point,  and  the  same  process 
repeated  several  times. 

The  sagittal  bandage  (Fig.  93),  a  X-bandage,  is  especially  suitable  for 
transverse  wounds  of  the  scalp. 

The  halter  bandage  (Fig.  94).  The  first  turn  begins  on  the  top  of  the 
head,  crosses  the  cheek  by  passing  under  the  chin,  and  returns  to  the  ver- 


FiG.  94.— Halter  Bandage. 


FlO.  95. — Capcllinc  Bandage. 


tex.  From  here  the  second  turn  runs  backwai'd  round  the  occiput ;  it  is 
then  carried  from  the  nape  of  the  neck  to  the  front,  round  the  anterior 
surface  of  the  chin  ;  lastly,  it  returns  to  the  nape  of  the  neck,  and  ascends 
again  to  the  vertex.  After  these  have  been  repeated  two  or  three  times, 


FIG.  96. — Four-tailed  Cap  for  the  Vertex.  FIG.  97.— Four-tailed  Cap  for  the  Occiput. 


the  third  turn  brings  it  to  a  conclusion  by  forming  a  circle  from  forehead 
to  occiput. 

The  capelline  (Fig.  95)  is  a  double-headed  bandage,  the  end  of  which 
passes  round  the  head  from  forehead  to  occiput,  and  fixes  the  turns  of  the 


320  THE    TREATMENT    OF    WOUNDS. 

other  end,  which  is  carried  alternately  over  the  right  and  left  parietal  bone, 
each  turn  overlapping  the  preceding  one. 

The  four-tailed  cap  (Figs.  96  and  97)  is  a  rectangular  handkerchief, 
three  times  as  long  as  broad,  and  slit  at  its  narrow  ends.  The  figures  show 
the  method  of  its  use. 

The  head-net  (Figs.  98  and  99)  may  be  made  of  coarse  cotton  twine. 
A  narrow  linen  ribbon,  drawn  through  the  meshes  of  its  lower  border,  will 
fix  it  in  a  circular  manner  round  the  forehead,  temples,  and  occiput  A 


Pio.  98. — Head-net  for  Keeping  Dressing  on  a  Wound.        Fio.  99. — Head-net  Used  for  Fixing  on  an  Ice-bag. 

second  ribbon,  which  is  tied  beneath  the  chin,  keeps  the  net  down,  and  a 
third  contracts  the  net  upon  the  vertex  like  the  string  of  a  purse.  It  may 
thus  be  made  to  adhere  firmly  to  the  surface  of  the  head  without  exercising 
too  much  pressure  or  causing  heat 

TREPHINING. 

Indications  for  the  Operation. — As  Professor  H.  B.  Sands  has  remarked 
in  the  paper  already  alluded  to,  read  before  the  New  York  Surgical 
Society  :  "  For  ages  past  no  surgical  procedure  has  been  the  subject  of 
keener  controversy,  and  the  diversity  of  opinion  which  still  prevails 
concerning  it  suffices  to  prove  that  the  question  of  its  value  is  yet 
unsettled,  and  that  it  is  one  of  inherent  difficulty  and  obscurity."  In  the 
opinion  of  this  surgeon,  trephining  is,  however,  plainly  indicated  in  all 
compound  fractures  of  limited  extent,  accompanied  with  depression  and 
comminution  of  the  bone,  even  though  not  attended  with  any  signs  of 
serious  injury  to  the  brain.  He  says :  "  Many  lives  which  would  other- 


INDICATIONS    FOB   TREPHINING.  321 

•wise  be  lost  are  saved  by  the  operation,  which  by  elevating  depressed  frag- 
ments, by  removing  fragments  that  are  loose  or  sharp,  and  by  permitting 
thorough  antiseptic  irrigation  of  the  wound,  reduces  to  a  minimum  the 
risk  of  intracranial  inflammation,  so  greatly  to  be  dreaded  in  this  class  of 
cases.  To  insure  success,  however,  the  operation  should  be  performed 
soon  after  the  injury,  and  with  strict  antiseptic  precautions.  I  recall  an 
instance  in  which,  many  years  ago,  I  unfortunately  delayed  the  operation 
until  the  third  day,  in  consequence  of  the  entire  absence  of  head 
symptoms.  When  these  occurred  I  trephined,  but  lost  the  patient,  who,  I 
believe,  might  have  been  saved  by  earlier  interference.  If  trephining  has 
not  been  performed  soon  after  the  accident,  and  the  wound  seems  to  be 
doing  well,  I  should  consider  it  objectionable  to  disturb  it  at  a  later  period, 
unless  the  operation  was  indicated  by  the  occurrence  of  decided  symptoms 
pointing  to  intracranial  mischief.  I  have  seen  cases  of  recovery  from  com- 
pound depressed  fractures  in  which  the  bone  was  not  elevated  ;  but  I  do 
not  remember  to  have  met  with  such  an  instance,  except  in  children,  who,  as 
is  well  known,  bear  head  injuries  much  better  than  is  the  case  with  adults. 

"  While  believing  that  trephining  is  to  be  recommended  in  ah1  cases  of 
compound  fracture  in  which  the  depression  is  marked,  but  of  no  great 
superficial  extent,  and  in  all  cases  of  punctured  fracture,  when  there  is 
reason  to  suspect  that  the  internal  table  is  extensively  splintered  or  de- 
pressed, I  am  strongly  opposed  to  active  interference  when  the  fracture  is 
of  great  extent,  and  when  the  depression  is  not  limited  or  abrupt.  It  is 
true  that  these  cases  are  usually  fatal ;  but  I  am  sure  that  nothing  can  be 
gained  by  the  extensive  operative  procedure  that  would  be  involved  in  any 
attempt  to  remedy  the  displacement  Aside  from  those  cases  in  which  the 
brain  has  suffered  irreparable  damage,  I  think  that  in  future  many  suc- 
cesses will  be  obtained  by  careful  antiseptic  treatment  of  the  wound,  such 
as  recommended  by  Lister  in  the  management  of  compound  fracture  of 
the  bones  of  the  extremities.  The  most  scrupulous  cleansing  of  the 
wound,  the  arrest  of  haemorrhage,  the  removal  of  foreign  bodies,  loose 
fragments  of  bone,  and  of  detached  portions  of  brain  matter,  if  present, 
followed  by  proper  drainage  and  dressings,  is,  in  my  judgment,  the  only 
means  which,  with  our  present  knowledge  promises  any  benefit  in  this 
nearly  desperate  class  of  injuries." 

Of  those  who  advocate  more  free  resort  to  this  operation,  Professor 
Briggs,  of  Nashville,  has  more  recently  written.1  In  this  paper  he  calls 


1  Annals  of  Anatomy  and  Surgery,  1883.  viii.,  59. 

21 


322  THE   TREATMENT    OF    WOUNDS. 

attention  to  the  frequency,  and  almost  impunity,  with  which  it  was  done 
by  the  ancients  and  by  strolling  charlatans  in  the  middle  ages.  With 
respect  to  its  adoption  he  divides  surgeons  into  three  classes — (1)  those 
who  reject  it,  (2)  those  who  only  practise  it  when  imperatively  demand- 
ed, and  (3)  those  who  recognize  it  as  a  valuable  prophylactic.  The 
mortality  after  it  is  certainly  high  ;  but  how  many  of  those  dying  are 
really  killed  by  the  trephine  ?  The  well-known  case  of  the  Count  of 
Nassau,  who  was  trephined  twenty-seven  times  by  Chadbourn,  proves 
the  operation,  as  such,  to  be  no  more  dangerous  than  other  capital 
operations.  The  South  Sea  Islanders  scrape  through  their  skulls  with 
pieces  of  glass.  Among  the  Cornish  miners  the  operation  is,  according  to 
Michel, l  one  of  daily  occurrence.  The  chief  danger  in  depressed  fractures 
is  not  the  compression,  for  the  brain  rapidly  adapts  itself  to  that,  but  the 
irritation  set  up  by  the  depressed  bone.  His  motto  is,  "  The  early  trephine 
is  gold,  the  late  trephine  is  lead."  The  risk  of  converting  a  simple  fract- 
ure of  the  skull  into  a  compound  one  can  by  no  means  equal  the  positive 
harm  that  threatens  the  integrity  of  the  brain  and  its  meninges  if  no 
operative  steps  are  taken.  Acting  on  this  plan,  that  if  cerebral  irritation 
clearly  point  to  a  local  focus  the  exploratory  trephine  should  be  used,  he 
has  never  had  occasion  to  regret  this  matter,  dreaded  by  many,  of  making 
a  compound  out  of  a  simple  fracture. 

Summing  up,  then,  and  giving  due  consideration  to  the  opinion  of  the 
older  masters  in  surgery  as  well  as  the  more  recent  (Bell,  A.  Cooper, 
Brodie,  Hewitt,  N6laton,  Bergmann),  we  may  make  out  the  list  of  indica- 
tions for  the  trephine  about  as  follows  : 

Simple  fracture,  with  loss  of  function  from  penetration  of  cerebral 
cortex  by  splinter  from  inner  table,  or  with  compression  from 
wound  of  a  meningeal  vessel 

Compound  fracture,  with  depression,  even  without  symptoms  of  com- 
pression, except  over  the  frontal  sinus  in  adults. 

Punctured  fractures,  even  without  symptoms. 

Coma,  with  signs  of  compression,  with  bruising  of  soft  parts,  but  with- 
out fracture  of  the  external  table. 

Haemorrhage,  either  to  tie  a  vessel  or  remove  a  clot  This  is  more  or 
less  included  in  the  above. 

1  Am.  Jour.  Med.  Sci.,  Oct.,  1879. 


OPERATION    OF   TREPHINING.  323 

Other  indications  not  so  directly  connected  with  our  subject  are  : 
Abscesses  of  brain. 
Epilepsy  or  mental   aberration   following  a   head   injury,  when  the 

lesion  can  be  localized. 
Bone  abscess  (frontal  sinus,  mastoid,  etc.). 
Purulent  meningitis  ?  ' 

In  discussing  this  part  of  the  subject,  the  term  trephining  has  been 
used  as  including  not  only  removal  of  a  disc  of  bone,  but  also  the  use  of 
the  bone  elevator  and  Hey's  saw.  The  facts  of  the  fractured  area  covering 
a  relatively  great  extent  of  surface,  or  the  depression  not  being  limited  or 
abrupt,  are  usually  held  as  counter-indications  for  operation  ;  yet  here,  as 
everywhere  else,  the  surgeon  must  be  guided  by  general  considerations  and 
by  the  special  features  of  a  given  case,  and  be  prepared  to  use  that  judg- 
ment without  which  he  can  in  nowise  be  considered  to  be  a  surgeon. 

The  Operation. — For  the  operation  are  needed,  besides  the  ordinary 
scalpel,  forceps,  etc.,  one  or  more  conical  trephines,  a  bone  elevator,  and  a 
Hey's  saw.  Sponges,  antiseptics,  assistants,  and  the  spray  being  ready,  the 
scalp  should  first  be  cleanly  shaved.  If  the  patient  be  unconscious  no 
anaesthetic  will  be  required,  at  all  events  at  first ;  otherwise  he  should  be 
anaesthetized.  An  existing  wound  should  be  enlarged  ;  else  the  bone  must 
be  exposed  by  a  crucial,  curved,  or  "I"-snaPe(l  incision  ;  the  pericranium  is 
also  raised  from  that  portion  where  it  is  intended  to  perforate.  All  bleed- 
ing vessels  should  be  caught  and  tied  as  cut.  Haemorrhage  being  checked 
the  surgeon  plants  the  trephine  on  the  place  selected,  the  centre-pin 
protruding,  and  turning  it  gently,  one  way  and  then  the  other,  sinks  the 
pin-point  till  the  teeth  have  cut  a  circular  groove.  The  centre-pin  is  then 
withdrawn  till  it  no  longer  appears  on  a  level  with  the  teeth.  The  trephine 
is  now  worked  with  gentle  motion,  withdrawing  it  frequently  to  brush  the 
groove  in  the  bone,  and  its  teeth,  with  the  little  brush  that  should  always 
accompany  the  instrument.  Complete  division  of  the  outer  table  and 
entrance  into  the  diploe  will  be  recognized  by  the  more  yielding  sensation 
to  the  hand  guiding  the  instrument,  and  the  altered,  more  bloody  character 
of  the  detritus  thrown  up  by  the  saw.  The  surgeon  must  never  forget 
that  children  and  aged  persons  have  no  diploe,  their  crania  being  therefore 

1  Gross :  Am.  Jour.  Med.  Sci.,  July,  1873,  p.  GO.  If  the  gynaecologist  can  open  the 
peritoneal  cavity  for  acute  peritonitis  with  success,  as  Tait  has  done,  why  cannot  the 
surgeon  open  the  meningeal  cavity  for  the  same  reason,  to  let  out  pus  ?— (P.) 


324  THE    TREATMENT    OF    WOUNDS. 

BO  much  the  thinner.  As  the  instrument  is  made  to  cut  more  deeply  it 
must  be  the  oftener  withdrawn  and  the  groove  explored  with  a  blunt 
probe,  by  which  one  will  be  able  to  distinguish  between  the  bone  and  the 
more  elastic  and  yielding  dura  mater.  If  the  probe  go  through  on  one 
side,  he  must  be  very  careful  to  press  the  trephine  only  on  the  other  side, 
and  to  avoid  lacerating  the  dura  with  its  teeth.  Extreme  caution  is  now 
required.  On  account  of  irregularities  of  the  inner  surface  of  the  skull  it 
may  be  impossible  to  cut  everywhere  through  the  whole  thickness  of  bone 
without  endangering  the  parts  beneath.  In  this  case,  even  at  the  risk  of 
causing  spiculse  of  bone,  the  disc  must  be  broken  out 

The  trephine  having  been  carried  as  far  as  deemed  judicious,  one  end 
of  the  elevator  is  inserted  under  the  disc,  and  with  the  margin  of  the  sound 
bone  as  a  fulcrum  it  is  pried  out  of  place,  the  elevator  point  being  in- 
troduced at  several  points  around  its  circumference  if  need  be.  When 
loose  from  bony  attachments  the  elevator  and  the  forceps  will  facilitate 
its  removal  Sometimes  the  combined  action  of  two  levers  may  be  ne- 
cessary. 

With  this  removal  of  a  disc  of  bone  the  prime  object  of  the  operation 
is  attained,  and  pus  or  blood  may  be  evacuated,  or  depressed  portions  of 
bone  may  be  raised  to  their  proper  level  by  prying  them  with  the  elevator. 
Before  closing  the  wound  all  sharp  points  should  be  removed  and  rough 
edges  smoothed  off  with  suitable  instruments.  If  a  coagulum  is  to  be  ex- 
tracted it  may  be  broken  down  with  the  bent  probe  and  washed  away  with 
a  stream  of  tepid  carbolized  water.  It  is  a  favorable  sign  when  the  dura 
rises  hi  proportion  as  clot  is  removed. 

We  have  described  above  the  typical  operation.  In  cases  of  commi- 
nuted fracture  it  may  be  possible  to  remove  the  fragments  with  the  eleva- 
tor and  forceps,  without  the  necessity  for  making  a  prior  opening.  Some- 
times a  projecting  piece  of  bone  may  be  removed  with  a  Hey's  saw  without 
requiring  the  trephine ;  this  fragment  thus  removed,  an  opening  is  made 
just  as  if  the  trephine  had  been  used. 

Certain  cautions  must  be  diligently  observed. 

Place  of  Applying  the  Trephine. — It  must  be  rested  by  its  centre-pin 
upon  sound  bone.  That  portion  of  broken  bone,  or  edge,  which  is  de- 
pressed always  carries  with  it  a  larger  portion  of  the  inner  table  than  an- 
swers to  the  diameter  of  the  hole  in  the  outer  table.  Hence  the  necessity 
for  observing  this  rule.  Moreover,  to  trephine  the  depressed  portion  might 
be  to  depress  it  still  more  during  the  operation. 


THE    USE    OF    THE   TREPHINE.  325 

Points  to  ivhich  the  Trephine  should  never  be  Applied. — The  line  of  the 
longitudinal  sinus,  the  occipital  bone  over  the  course  of  the  large  sinuses, 
the  frontal  over  the  frontal  sinus,  and  the  parietal  over  the  course  of  the 
middle  meningeal  artery — at  least  its  lower  portion.  A  point  an  inch  and 
a  quarter,  or  half,  back  of  the  external  angle  of  the  orbit  marks  the  site  of 
the  artery.  If  necessity  arise  for  application  of  the  trephine  over  the  fron- 
tal sinus,  the  outer  table  should  be  first  removed  and  then  the  inner. 

Should  the  circumstances  of  the  case,  the  bulging  of  the  dura  mater 
and  its  discoloration  lead  to  the  supposition  that  pus  or  blood  be  present 
beneath  it,  it  would  then  be  legitimate  to  incise  it  and  remove  whichever 
might  present. 

Whenever  removal  of  one  disc  proves  insufficient  for  the  elevation  of 
bone  or  removal  of  clot  the  surgeon  is  justified  in  removing  a  second  anc? 
a  third  even,  selecting  his  points  in  accordance  with  the  rule  above  given. 

The  following  plates,  Figs.  100  and  101,  taken  from  Charles  Bell's 
"Illustrations  of  the  Great  Operations  of  Surgery"  (London,  1821),  with 
their  commentary  and  explanation,  will  serve  to  illustrate,  much  better 
than  a  long  description,  some  of  the  practical  points  in  the  operation. 

After-treatment. — There  is  little  to  be  said  with  reference  to  the  after- 
treatment  Perfect  repose,  light  diet,  and  sedatives,  pro  re  nata,  in  the 
way  of  therapeutics.  The  wound  should  be  dressed  strictly  antisepticaily, 
with  a  few  catgut  threads  for  drainage  in  one  or  two  corners  of  the  wound. 
A  reasonably  firm  compress  must  be  made  over  the  site  of  the  operation, 
both  to  repress  any  tendency  to  hernia  durse  or  hernia  cerebri,  and  to  keep 
the  pericranium  and  scalp  in  proper  apposition  with  the  parts  beneath. 
The  scalp-wound,  of  course,  is  neatly  closed  with  sutures.  But  if  pus 
have  been  evacuated  from  within  the  cranium,  it  will  be  necessary  to  make 
an  open  wound,  and  to  place  the  head  in  the  most  favorable  position  pos- 
sible for  drainage. 

ENLARGING   OPENINGS   IN   THE   CALVARIA. 

For  the  purpose  of  enlarging  openings  which  already  exist  in  the  bones 
of  the  cranium  for  the  elevation  of  depressed  fragments,  the  extraction  of 
splinters  of  bone  or  foreign  bodies,  and  to  provide  for  the  adequate  cleans- 
ing and  drainage  of  penetrating  wounds  of  the  skull,  gouge-forceps  may  be 
conveniently  used,  as  in  Fig.  102  by  means  of  which  the  edges  may  be 
gnawed  away,  and  the  opening  quickly  enlarged  in  any  direction.  Es- 
march,  in  his  "Handbook,"  p.  281,  recommends  that  the  sawing  out  of  o 


326 


THE   TREATMENT    OF    WOUNDS. 


FIG.  100.— Examples  of  Fracture  of  Skull,  and  Application  of  Trephine  (after  Cfiat.  Sell). 


THE   USE   OF   THE   TREPHINE.  327 


EXPLANATION  OF  FIG.  100. 

1.  A  skull  showing  various  examples  of  fracture.    A,  a  triangular  portion  of  the 
os  frontis,  fractured  and  depressed.     B,  the  three  perforations  found  necessary  for  its 
elevation  and  extraction.     The  edge  of  the  inner  table  being  found  to  shelve  under 
the  sound  bone  made  the  second  and  third  perforation  necessary.     This  was  a  mis- 
take, but  one  which  may  happen.     D,  a  point  where  the  trephine  was  employed  for  a 
fissure  and  fracture  of  the  os  frontis  represented  at  its  right  side  ;  a  second  perfora- 
tion was  made  on  the  sound  bone  a  little  higher  up,  still  the  bone  could  not  be  ex- 
tracted ;  the  trephine  was  then  applied  at  E,  and  the  bone  lifted  up.     It  should  have 
been  applied  at  E  in  the  first  place.     F  is  a  fracture  with  depression  at  the  lower 
angle.     The  trephine  was  placed  at  G.     It  ought  to  have  been  a  large  one,  and  placed 
at  H,  by  which  a  portion  of  bone  would  have  been  saved  and  a  more  favorable  form 
of  opening  obtained.     By  perforating  at  G  an  acute  angle  of  bone  was  left  between 
G  and  F. 

2.  Represents  the  piece  of  bone  removed  from  A,  with  its  inner  table  projecting 
beyond  the  outer. 

4.  The  button  of  bone  removed  in  order  to  elevate  the  fragment  represented  in  3. 
Here,  by  careless  work,  the  surgeon  might  have  pressed  on  the  depressed  portion  with 
the  trephine,  and  thua  depressed  and  chafed  the  dura. 

5  and  7.  Buttons  of  bone  having  inequalities  on  their  lower  surfaces,  showing  the 
necessity  for  extreme  caution  during  the  operation. 

6.  Another  button,  having  considerable  inner  table  attached  to  it,  as  occurs  when 
the  surgeon  is  obliged  to  break  up  the  circular  portion. 

In  1,  instead  of  the  trephine,  a  Hey's  saw  might  have  been  used  to  cut  across  the 
base  of  the  fragment  at  H,  but  there  is  always  more  danger  of  wounding  the  dura 
when  using  the  saw,  and  it  is  more  difficult  to  introduce  the  elevator. 


328 


THE    TREATMENT    OF    WOUNDS. 


53  4 

FlO.  101 — A.  Fractured  Skull  after  the  Application  of  the  Trephine  and  the  Removal  of  the  Fragments 
(after  Chatt.  Bell). 

1.  Shows  the  parts  after  the  application  of  the  trephine  and  removal  of  the  frag- 
ments.    A,  B,  the  flaps  of  integument ;  C,   the  cranium  ;  and  D,   the  dura  mater 
exposed. 

2.  Sketch  of  the  fractured  bone.     A,  B,  C,  the  three  portions  of  fractured  bone, 
with  depressed  edges,  which,  being  sharp,  are  irritating  the  dura ;  they  must,  there- 
fore, be  removed.     They  are.  moreover,  eo  separated  from  their  attachments  as  to 
have  lost  their  vitality.     There  being  no  "  purchase"  for  the  elevator,  the  trephine 
is  applied  at  D,  and  the  broken  pieces  elevated  and  picked  away. 

3.  Two  discs  of  bone  cut  by  the  trephine,  showing  the  varying  thickness  of  the 
skull. 

4.  Exfoliation  of  bone  after  use  of  the  trephine.  • 

6.  Shows  the  two  tables  of  the  skull,  with  the  d  ploe  between. 


ENLARGING    OPENINGS   IN   SKULL. 


329 


circular  piece  of  bone  by  the  trephine  be  resorted  to  only  in  those  cases  in 
which  there  is  no  opening  in  the  skull.  If  there  is  but  a  narrow  fissure 
which  has  to  be  widened,  he  would  use  a  gouge,  a  common  carpenter's 


FIG.  102— Biting  off  the  Edge  of  Bone,  in  a  Fracture  of  the  gkull,  with  Gouge-forceps  (E»march}. 


chisel,  and  a  wooden  mallet,  with  which  small,  sharp  blows  should  be  dealt 
upon  the  chisel  obliquely  placed  upon  the  bone  (Fig.  103).  When  the 
opening  has  been  sufficiently  widened,  the  gouge-forceps  can  be  used  for 


Flo.  103.— ThetTsse  of  the  Gouge  and  Mallet  to  Enlarge  an  Opening  in  the  Skull  (Esmarch). 

its  further  enlarging,  as  may  be  necessary.  When  the  object  is  sufficiently 
exposed,  it  is  raised  by  an  elevator,  grasped  with  forceps,  and  carefully  ex- 
tracted. 


330  THE    TREATMENT    OF    WOUNDS. 

WOUNDS   OF   THE   FACE,   ETC. 

Wounds  of  the  eye  are  usually  relegated  to  the  specialist  in  that  depart- 
ment, yet  it  is  essential  that  every  practitioner  should  at  least  know  what 
"first  help  "to  render.  No  careless  efforts  should  be  made  to  remove 
penetrating  particles  or  bodies,  but  the  eye  should  be  carefully  cleansed,  a 
few  drops  of  a  2  to  4  grain  solution  of  atropia  be  instilled  to  dilate  the  pupil 
and  allay  pain  and  irritation,  the  lid  should  then  be  lightly  bandaged 
down,  the  patient  put  absolutely  at  rest,  and  cold  applications  made, 
with,  perhaps,  the  administration  of  a  cathartic.  For  further  information 
the  reader  is  referred  to  any  of  the  standard  treatises  on  ophthalmology. 

Wounds  of  the  interior  of  the  ear  should  first  be  treated  with  warm 
water ;  in  fact,  warm  water  is  the  only  fluid  that  ever  should  be  used  in  the 
ear  except  by  direction  of  the  professed  aurist.  If  pain  be  extreme, 
though,  a  few  drops  of  a  solution  of  morphia,  with  a  little  atropia  in  glyce- 
rine may  be  instilled.  Beyond  this  nothing  but  hot  water,  made  antiseptic, 
and  possibly  alkaline,  should  ever  be  used. 

Incised  wounds  of  the  eyelids  may  be  united  like  other  wounds.  The 
approximation  should  be  as  neat  as  possible  that  the  resulting  scar  may  be 
slight  Fine  silk  should  be  used. 

A  variety  of  penetrating  wounds  of  the  face  may  be  met  with.  Knife- 
blades  and  metallic  instruments  occasionally  enter  to  the  depth  of  an  inch 
or  more.  If  no  vessel  be  severed,  repair  usually  goes  on  speedily.  The 
less  such  a  wound  is  disturbed,  as  by  probing,  the  better.  A  little  wad 
of  antiseptic  cotton  bound  on,  or  occlusion  made  by  iodoform  collodion, 
over  which  cold  may  be  applied,  will  probably  be  all  sufficient.  If  com- 
pression do  not  check  haemorrhage  a  hare-lip  pin,  or  curved  needle  with  a 
figure  of  eight  ligature,  or  a  deep  stitch  on  either  side  the  opening,  may 
be  resorted  to,  both  needle  and  silk  having  been  carbolized.  If  serious 
haemorrhage  indicate  the  division  of  some  arterial  trunk,  the  wound  must 
be  enlarged  enough  to  permit  application  of  a  ligature  to  each  end  of  the 
divided  vessel,  or  possibly  a  ligature  below  the  wound  may  be  required. 
Advantage  may  also  be  taken  of  the  styptic  powers  of  hot  water. 

Should  fracture  of  the  nasal  bones  complicate  a  case,  the  parts  may  be 
supported  by  tampons  of  cotton  from  within  the  nose,  or,  better  still,  accord- 
ing to  the  method  recommended  by  Mason,1  they  maybe  supported  upon  a 
strong  needle  passed  under  them  from  one  side  to  the  other.  Should  se- 

1  Annals  of  Anatomy  and  Surgery.  1881,  iii,  107,  197. 


WOUNDS    OF   THE    FACE.  331 

vere  epistaxis  occur,  a  douche  of  water  as  warm  as  can  possibly  be  toler- 
ated should  be  given,  after  which  cold  may  be  applied  to  the  back  of  the 
head  and  the  hands  raised  above  it 

In  any  of  the  great  variety  of  gunshot  wounds  that  may  occur,  the  rule 
should  be  as  follows :  If  no  serious  symptoms  indicate  a  lesion  incapable 
of  spontaneous  recovery,  a  simple  antiseptic  occlusion  of  the  wound  will  be 
all  that  is  required ;  no  probe  should  be  introduced.  Any  symptom  of 
really  grave  import  can  be  recognized  without  the  probe.  Should,  on  the 
contrary,  the  general  and  particular  features  of  the  case  indicate  some 
operative  measure,  it  should  be,  if  possible,  postponed  (of  course  .not  too 
long)  till  everything  is  ready — the  patient's  accommodations,  the  anaes- 
thetic, instruments,  and  antiseptic  dressings,  as  well  as  assistants  and 
nurses.  And  all  probing  and  investigating  should  have  been  omitted  until 
then,  when  all  can  be  done  at  one  sitting  and  with  better  results. 

The  same  will  hold  good  with  regard  to  injuries  by  larger  or  foreign 
bodies,  as,  e.g.,  fragments  of  glass,  bombs  or  shell,  or  splinters  of  wood. 
Primary  antiseptic  occlusion  on  the  battle-field,  or  place  where  injured,  and 
all  operative  measures  later  when  they  can  be  carefully  attended  to. 

Intractable  bleeding  sometimes  occurs  after  extraction  of  teeth,  espe- 
cially in  so-called  "bleeders."  In  these  cases  hot  water  may  serve  the  pur- 
pose, but  it  will  probably  be  necessary  to  pack  the  cavity  with  some  styptic, 
and  then  make  compression  by  stuffing  that  side  of  the  mouth  and  binding 
the  jaws  together. 

It  may  be  possible  to  replace  a  tooth  that  has  been  wrenched  or  knocked 
out  of  its  socket,  provided  the  alveolar  process  be  not  badly  broken,  and  to 
fasten  it  by  wire  or  silk  to  other  teeth  or  by  binding  the  jaws  together. 

When  fracture  of  any  of  the  larger  bones  of  the  face  occurs  along  with 
an  external  wound,  making  a  compound  fracture,  the  general  rules  govern- 
ing the  treatment  of  such  injuries  should  be  observed  ; — approximation  of 
fragments,  perhaps  by  wire  or  chromic  catgut,  disinfection  of  the  entire 
wound,  provision  for  drainage,  accurate  adaptation  of  superficial  wound, 
and  suitable  inter-dental  or  external  support 

In  wounds  cutting  through  the  entire  thickness  of  lip  or  cheek  it  should 
be  the  effort  to  coapt  the  surfaces  of  mucous  membrane  as  carefully  as 
those  of  the  integument  Otherwise  there  are  no  particular  indications 
about  wounds  of  the  soft  parts  of  the  face  or  external  ear  differing  from 
those  in  other  parts  of  the  body.  If,  however,  the  surgeon  particularly  desire 
to  avoid  scarring,  he  may  do  as  Pancoast  has  suggested  with  reference 


332  THE    TREATMENT    OF   WOUNDS. 

to  incisions  made  during  plastic  operations  about  the  face — he  may  take 
a  li ttle  more  time  and  bevel  the  edges,  so  that  one  shall  tend  to  lap  or  slide  a 
little  way  under  the  other,  thus  making  the  cicatrix  a  mere  linear  one. 

We  may  add  that  portions  of  the  cartilaginous  part  of  the  external  ear 
which  have  been  entirely  removed  may  be  replaced,  provided  not  too  long 
an  interval  have  elapsed,  with  expectation  of  reunion  in  quite  a  large  pro- 
portion of  cases. 

Wounds  of  the  Mouth. ' — Wounds  opening  into  the  buccal  cavity,  as  after 
extirpation  of  the  tongue,  etc.,  should  be  lightly  packed  with  iodoform- 
gauze.  The  adhesive  gauze  is  here  particularly  valuable,  because  by  its 
adhesive  properties  it  attaches  itself  to  the  walls  of  the  wound,  thereby 
preventing  its  being  swallowed  or  causing  suffocation,  while  the  iodoform, 
adhering  to  the  gauze,  is  not  apt  to  be  removed  by  the  secretions  of  the 
mucous  membrane.  The  gauze,  cut  in  strips  one-half  to  three-fourths 
of  an  inch  in  width,  should  be  brought  into  intimate  contact  with  the 
wound-surfaces,  so  as  to  fill  all  fissures  and  recesses,  and,  if  necessary, 
should  even  be  fastened  by  stitches.  In  wounds  to  which  the  gauze  can- 
not be  thus  applied,  as,  for  example,  those  of  the  throat  and  palate,  the 
iodoform  in  powder  should  be  daily  insufflated.  Drainage  is  called  for 
only  after  extirpation  of  the  tongue  and  other  wounds  involving  the  floor 
of  the  mouth,  in  which  there  is  already  an  external  opening.  Parenchy- 
matous  haemorrhage  is  controlled  by  the  gauze.  Serum;  which  at  first  may 
ooze  through,  may  be  absorbed  by  sponges  fastened  on  sponge-holders 
firmly  pressed  against  the  dressings. 

The  gauze,  which  will  form  in  time  a  solid  mass  with  the  various  secre- 
tions, should  remain  in  situ  8  to  14  days,  till  it  is  spontaneously  detached. 

Secondary  haemorrhage  is  prevented,  and  cleansing  of  the  buccal  cavity 
and  teeth,  formerly  carefully  attended  to,  is  of  less  importance. 

If  the  filling  of  the  wound-cavity  has  been  performed  with  exactness, 
there  will  be  no  reaction,  secretions  will  be  at  a  minimum,  the  patient  will 
feel  well,  will  experience  no  pain,  and  the  mouth  will  be  free  from  unpleas- 
ant odor.  Only  the  superficial  layers  of  the  gauze  will  need  a  renewal,  as 
soon  as  they  are  soiled  by  food,  saliva,  etc.,  or  if  the  iodoform  in  any  con- 
siderable quantity  is  washed  away,  the  powdered  iodoform  should  be 
dusted  upon  the  dressing,  more  particularly  where  the  gauze  has  separated 
from  the  edges  of  the  wound. 

1  Wolfler :  Wundbefuindlung  im  Munde,  Archio  far  klinische  Chirurgie,  xxvii., 
419.  Hacker  :  Anleitung  ziir  antiseptisclien  WundbehancUuny,  p.  31. 


CHAPTER   XIX. 
WOUNDS  OF  THE  NECK  AND  OF  THE  THOBAX. 

Wounds  of  the  Larynx  or  Trachea — Punctures — Longitudinal  Wounds — Transverse 
Wounds — Suturing  the  Trachea — Antisepsis — Tracheal  Canula — Intra-tracheal 
Polypi — Haemorrhage  into  Trachea —  Wounds  of  Pharynx  or  (Esophagus — Swal- 
lowing Interdicted — (Esophageal  Tube — Primary  Importance  of  Deep  Union — 
Longitudinal  Wounds — Gunshot  Wounds — Transverse  Wounds — Wounds  of  the 
Great  Vessels  of  the  Neck — Arteries — Vertebral  Arteries — Internal  Jugular  Vein — 
Lateral  Ligature — Cases  of  Parkes,  Allis,  Gerster,  Lange,  Lidell,  and  J.  E.  Pil- 
cher — Non-penetrating  Wounds  of  the  Thorax — Wounds  of  Internal  Mammary  and 
Intercostal  Arteries — Penetrating  Wounds  of  the  Thorax — Heart  and  Pericardium 
— Lungs — Pleurae — Haemothorax — Pneuinothorax — Emphysema — Empyema  and 
Hydrothorax — Resume. 

WOUNDS   OF   THE  NECK. 

THE  wounds  of  the  neck  which  present  peculiarities  that  demand  special 
examination  are  those  deep  wounds  which  penetrate  the  larynx  or  trachea, 
the  pharynx  or  oesophagus,  or  involve  the  great  vessels  of  the  neck. 

WOUNDS  OF  THE  LARYNX  OR  TRACHEA. — Simple  punctures  of  the  air-tube, 
as  in  cases  of  stab-wounds,  usually  unite  by  first  intention,  without  intro- 
ducing any  complication  in  the  course  of  the  more  superficial  wound. 
Spontaneous  apposition  of  the  edges  of  longitudinal  wounds  of  the  trachea 
may  be  depended  on  by  reason  of  the  resistance  to  separation  exercised  by 
the  cartilaginous  rings  of  its  wall  The  closure  of  such  a  wound  by  pri- 
mary adhesion  is  the  rule.  Transverse  wounds  may  be  made  to  gape  by 
extending  the  neck.  In  such  cases  the  head  should  be  depressed  toward 
the  chest  sufficiently  to  bring  the  sides  of  the  wound  in  contact,  where  it 
should  be  kept  either  by  the  occipito-sternal  handkerchief  of  Mayor  (Fig. 
104),  or  by  some  other  apparatus  acting  on  the  same  principle.  Coaptation 
of  the  trachea!  wound,  in  transverse  wounds,  may  be  assisted,  if  the  case 
seem  to  require  it,  by  introducing  sutures  through  the  peritracheal  fascia, 
that  ensheathes  the  tube ;  this  peritracheal  fascia!  sheath  has  sufficient  body 


334. 


THE    TREATMENT    OF    WOUNDS. 


to  make  its  suture  in  such  cases  a  valuable  resource  in  making  accurate 
adjustment  and  in  steadying  the  wound-edges  in  their  proper  relations  to 
each  other  in  those  comparatively  rare  instances  in  which  the  trachea  or 
larynx  has  suffered  transverse  division  through  a  large  part  or  the  whole 
of  its  circumference.  If  catgut  is  used  for  such  a  purpose,  it  should  be 
cut  off  short  in  the  wound.  If  silk,  one  end  should  be  brought  out  through 
the  superficial  wound,  and  the  suture  regarded  in  the  light  of  an  ordinary 
ligature. 

Close  approximation  of  the  more  superficial  wound-surfaces,  and  their 
suturing,  should  not  be  practised  to  a  degree  that  would  embarrass  the 
free  escape  of  any  air,  or  mucus,  or  blood,  that  might  be  forced  out  of  the 


Fig.  104. — Occipito-sternal  Handkerchief  for  Approximating  Transverse  Wounds  of  the  Neck. 

trachea  through  the  wound  in  its  wall  by  cough  or  in  ordinary  expiration. 
Approximation,  with  efforts  to  obtain  primary  union,  should,  however,  be 
made  of  all  portions  of  the  wound,  with  the  exception  named. 

The  entrance  of  sepsis  into  wounds  involving  the  air-tube  cannot  be 
prevented,  so  that  vigilant  effort  is  required  to  antidote  its  effects.  The 
free  escape  of  all  secretions  should  receive  careful  attention  that  it  be  per- 
fectly secured.  As  an  antiseptic  application  the  bismuth  lotions  of  Kocher 
(p.  89),  are  particularly  applicable.  By  their  use,  the  secondary  suture, 
as  practised  by  that  surgeon,  may  be  employed  on  the  second  or  third  day 
with  the  result  of  hastening  greatly  the  period  of  repair  in  favorable  cases. 


WOUNDS    OF    THE    TRACHEA.  333 

In  cases  in  which  there  is  considerable  loss  of  substance  of  the  wall  of 
the  larynx  or  trachea,  great  care  must  be  exercised*to  prevent  the  entrance 
into  the  trachea  of  septic  secretions.  One  of  the  most  frequent  and  fatal 
complications  of  such  injuries,  as  well  as  of  similar  injuries  of  the  mouth, 
is  broncho-pneumonia,  from  the  inhalation  of  septic  matters  from  the 
wound.  For  the  prevention  of  such  a  complication,  a  suitable  canula 
should  be  kept  in  place  in  the  tracheal  opening,  and  the  surrounding 
wound-cavity  should  be  kept  packed  lightly  with  adhesive  iodoform-gauze, 
until  its  cicatrization  is  well  advanced.  The  use  of  a  similar  canula  will 
also  be  required  for  purposes  of  respiration,  if  that  portion  of  the  air-tubp 
above  the  wound  should  become  stenosed  from  any  cause,  as  inflammatory 
oedema,  diphtheritic  exudate,  or  cicatricial  contraction. 

The  opening  of  the  canula  should  be  kept  covered  by  a  moist  and  warm 
sponge  to  purify  and  moderate  the  temperature  of  the  inhaled  air,  and 
thus  to  guard  against  bronchial  irritation  from  cold  or  dust-laden  air. 

Exuberant  granulations,  forming  polypoid  excrescences  projecting  into 
the  trachea,  not  infrequently  form  at  one  angle  of  a  wound  in  the  trachea 
which  has  been  kept  distended  by  a  canula.  They  are  formed  by  the  ex- 
cessive development  of  the  granulations,  which  spring  up  to  fill  in  the 
angles  of  the  tracheal  wound  not  filled  by  the  canula.  Their  presence  may 
be  a  source  of  dangerous  embarrassment  to  the  respiration  when  the  canula 
is  removed.  They  should  be  destroyed  by  the  application  of  caustics,  or 
by  avulsion,  followed  by  cauterization  of  their  bases.  Whatever  operative 
procedure  may  be  necessary  to  make  them  accessible  to  the  required  appli- 
cations should  be  done.  Whenever  a  prolonged  use  of  a  canula  is  re- 
quired, watch  should  be  kept  for  any  signs  of  their  development,  and  their 
growth  repressed  from  the  first. 

The  escape  of  blood  into  the  trachea,  to  the  extent  even  of  producing 
suffocation,  is  a  complication  that  should  not  escape  the  thought  of  the 
surgeon  in  the  cares  which  he  gives  to  the  wound.  It  is  to  be  prevented 
by  thoroughness  in  the  primary  hasmostasis,  and  by  the  non-closure  of  the 
external  wound.  When  blood  in  any  quantity  has  already  been  poured 
into  the  trachea,  it  should  be  removed  at  once  by  forcibly  compressing 
the  chest  while  the  patient  is  held  with  head  and  neck  hanging  down,  and 
by  the  introd\iction  of  forceps,  armed  with  sponges,  into  the  trachea 
through  the  wound,  which  may  be  enlarged,  if  necessary,  to  admit  of 
being  cleansed.  A  syringe,  if  at  hand,  may  also  be  used  to  suck  out  the 
blood. 


S3 6  THE    TREATMENT    OF    WOUNDS. 

WOUNDS  OF  THE  PHARYNX,  OR  THE  (ESOPHAGUS. — The  pharynx,  or  the 
oesophagus,  may  be  wounded  from  within,  or  from  without  In  the  former 
case,  portions  of  the  ingesta,  in  the  act  of  eating  or  drinking,  may  escape 
into  the  connective-tissue  of  the  neck,  and  produce  purulent  infiltration  of 
its  loose  substance.  If  the  wound  is  in  the  posterior  wall  of  the  tube,  the 
suppurative  gatherings  may  burrow  into  the  posterior  mediastinum  below. 
These  dangers,  and  the  requirements  of  "  rest "  for  the  wound,  make  it 
necessary  that  the  functions  of  the  canal  in  swallowing  food  shall  be  held 
in  abeyance  for  a  time.  The  patient  must  fast  for  the  first  days,  until  ad- 
hesion of  the  wound-edges  has  taken  place.  He  should  be  sustained  by 
nutritive  enemas,  which  alone  may  be  sufficient  to  sustain  him  during  the 
period  required.  Great  thirst  may  be  alleviated  by  rinsing  the  mouth  with 
lemon-juice  or  ice-water,  but  all  attempts  at  swallowing  should  be  rigor- 
ously interdicted.  If  the  rectal  alimentation  be  insufficient  or  impracti- 
cable, a  flexible  tube  should  be  introduced  into  the  oesophagus  to  a  point 
beyond  the  wound  and  nutritious  fluids  be  supplied  to  the  stomach  through 
this.  Such  a  tube,  introduced  through  the  nose,  has  been  left  in  situ  for  a 
long  time,  and  the  prolonged  support  of  the  patient  successfully  accom- 
plished through  it  This  physiological  rest  of  the  oesophagus  should  be 
observed  in  all  wounds  of  its  walls.  Cases  in  which  a  wound  from  with- 
out has  reached  and  opened  the  pharynx  or  the  oesophagus,  are  less  liable 
to  be  attended  by  phlegmonous  infiltration  of  the  tissues  of  the  neck,  or 
by  other  septic  accidents.  The  wound  in  the  alimentary  canal  is,  or,  in 
many  other  cases,  may  be  made  accessible  to  treatment  to  secure  its  pri- 
mary union,  and  the  external  wound,  by  the  drainage  that  it  affords,  is  a 
safeguard  against  the  retention  of  irritating  matters. 

The  chief  end  to  which  treatment  must  be  directed  is  to  secure,  first, 
union  of  the  wound  in  the  pharyngeal  or  the  oesophageal  wall  A  simple 
longitudinal  wound,  as  that  inflicted  in  the  operation  of  cesophagotomy, 
presents  little  difficulty.  There  is  no  tendency  to  gaping,  coaptation  is 
spontaneous  and  perfect  as  long  as  no  attempt  at  swallowing  food  is  made, 
the  external  wound  is  approximated  and  treated  according  to  the  require- 
ments of  incised  wounds  in  general,  and  primary  union  results. 

Gunshot  wounds  of  this  tube  do  not  admit  of  primary  antiseptic  oc- 
clusion. They  should  be  treated  by  enlargement  of  the  external  wound, 
and  adequate  provision  for  free  escape  of  wound-secretions  and  debris 
from  the  deeper  parts  of  the  wound.  Drainage  tubes  should  be  used,  and 
the  wound,  after  thorough  primary  disinfection  by  a  carbolic  acid  lotion, 


WOUNDS    OF    VESSELS    OF    NECK.  337 

should  be  kept  lightly  stuffed  with  iodoform  gauze  and  be  made  to  "  heal 
from  the  bottom." 

Transverse  incised  wounds  should  be  sutured,  whenever  the  wound  in 
the  tube  is  accessible,  or  can  be  rendered  so  by  a  proper  enlargement  of 
the  external  opening.  Aseptic  silk  thread  will  make  the  most  convenient 
material  for  the  suture.  The  sutures  should  not  include  the  mucous  mem- 
brane, but  only  the  submucous  and  muscular  coats.  The  interrupted  form 
should  be  used,  and  the  intervals  should  be  small,  not  exceeding  the  fourth 
of  an  inch.  They  should  be  cut  off  close.  The  external  wound  should  be 
cleansed  and  disinfected,  and  approximated  with  a  view  to  secure  union  by 
first  intention  throughout.  The  head  should  be  kept  in  a  position  to  relax 
the  wounded  structures  and  prevent  gaping. 

WOUNDS  OF  THE  GREAT  VESSELS  OF  THE  NECK. — Arteries. — Should  either 
of  the  main  arterial  trunks  of  the  neck  be  wounded,  the  rule  to  expose  the 
wounded  vessel  and  to  ligate  it  above  and  below  the  wound  is  imperative. 
If  large  collateral  branches  be  cut,  the  same  rule  should  be  followed,  if 
practicable,  and  the  practicability  of  the  procedure  will  largely  depend 
upon  the  anatomical  knowledge  and  the  operative  dexterity  of  the  surgeon. 
The  following  comment  on  the  subject  of  haemorrhage  and  ligations  in 
wounds  and  injuries  of  the  neck  occurring  during  the  War  of  the  Rebel- 
lion, is  by  its  surgical  historian. ' 

"  Grouping  the  ligations  of  the  large  vessels  of  the  neck,  performed  on 
account  of  gunshot  wounds  of  the  face  or  of  the  neck,  we  have  a  total  of 
seventy-five  ligations  of  the  common  carotid,  with  a  mortality  of  seventy- 
eight  per  cent.  .  .  .  Nowhere  else,  not  even  in  wounds  of  the  forearm 
or  legs,  in  which  the  brachial  or  femoral  may  have  been  tied,  does  the 
operation  of  Anel  appear  to  greater  disadvantage.  Tying  the  common 
trunk  for  injuries  of  the  smaller  vessels  of  the  head  or  neck  is  an  operation 
based  on  a  fallacious  interpretation  of  the  anatomical  and  physiological  re- 
lations of  the  region.  Nothing  that  is  not  corroborative  of  Guthrie's 
admirable  suggestions  is  found  in  the  preceding  cases.  If  the  indolent 
or  timid  surgeon,  who,  to  control  bleeding  from  minor  branches  of  the 
carotid,  prefers  to  stuff  the  wound  with  styptics,  or  to  perform  the  easy 
operation  of  tying  the  common  trunk,  rather  than  to  seek  in  the  difficult 
anatomy  of  the  maxillary  and  thyroid  regions  to  place  double  ligatures  at 
the  bleeding  point,  he  may  temporize,  or  may  associate  his  name  with  the 

'Otis:  Med.  and  Surg.  History  of  the  War  of   the  Rebellion.     Part  I.,  vol.  ii., 

Surgical  History,  p.  423. 
22 


338  THE   TREATMENT    OF    WOUNDS. 

necrology  of  ligations  ;  but  if  his  patient  recover,  it  will  generally  be  found 
to  be  under  circumstances  in  which  the  surgeon's  operative  intervention 
was  uncalled  for." 

Vertebral  Arteries. — An  exception  to  the  preceding  statements  is  to  be 
made  in  the  case  of  wounds  of  the  vertebral  arteries.  The  difficulties 
which  surround  the  treatment  of  wounds  of  these  vessels  are  very  great. 
Almost  all  the  recorded  cases,  and  their  number  is  not  small,  have  proved 
fatal  We  quote  the  following  observations  from  Lidell : '  "  Ligature  of 
the  vertebral  artery  for  practical  purposes  is  impossible  except  in  a  portion 
about  two  and  three-eighths  inches  long,  between  its  origin  and  its  entrance 
into  the  transverse  foramen  of  the  sixth  cervical  vertebra.  In  this  part  of 
its  course  it  has  been  successfully  tied  by  Smyth,  of  New  Orleans,  for  re- 
gurgitating haemorrhage  ;  in  this  part,  also,  it  has  been  tied,  together  with 
the  inferior  thyroid  artery,  by  Maisonneuve,  in  order  to  arrest  haemorrhage 
attending  a  shot  wound  of  the  neck — with  success  as  far  as  stopping  the 
haemorrhage  and  extracting  the  ball  was  concerned,  though  death  occurred 
from  infiltration  of  pus  into  the  spinal  canal,  and  consequent  inflammation. 
But  these  successes,  complete  and  partial,  afford  some  encouragement. 
Having  determined  by  exploring  the  wound  with  a  finger,  or  by  any  other 
means,  that  the  vertebral  artery  is  punctured  in  this  part  of  its  course,  the 
bleeding  point  should  at  once  be  laid  bare,  and  a  ligature  should  be  put 
round  the  artery  on  each  side  of  the  aperture.  But  when  the  exploration 
shows  that  the  artery  is  wounded  above  the  point  where  it  enters  the  fora- 
men of  the  transverse  process  of  the  sixth  cervical  vertebra,  how  can  we 
suppress  the  bleeding  and  save  the  patient  ?  We  cannot  tie  the  artery  in 
the  wound  ;  and  to  tie  it  in  the  first  part  of  its  course,  on  Anel's  plan, 
would  fail,  because  the  two  vertebrals  unite  to  form  the  basilar  artery  at 
the  base  of  the  brain,  and  therefore  regurgitating  haemorrhage  would  occur 
in  the  wound  whenever  the  direct  haemorrhage  might  be  stopped  in  this 
way.  Distal  ligature  of  this  artery,  between  the  occipital  bone  and  the 
atlas,  as  suggested  by  Dietrich,  would  be  both  difficult  in  performance  and 
uncertain  in  result.  There  remains,  then,  only  the  operation  of  plugging 
the  wounded  artery,  a  measure  which  has  been  successfully  employed  in 
one  case  by  Dr.  Kocher,  of  Bern. 

"  On  dilating  the  wound  hi  the  neck  by  suitable  incisions,  both  longi- 
tudinal and  transverse,  and  removing  the  coagula,  the  blood  was  seen  to 
come  from  a  point  between  the  transverse  processes  of  two  vertebrae,  ap- 

1  International  Encyclopaedia  of  Surgery,  iii.,  118. 


WOUNDS    OF   INTERNAL    JUGULAR    VEIN.  339 

par'ently  the  fifth  and  sixth.  Arterial  blood  escaped  from  both  the  central 
and  peripheral  portions  of  the  artery  ;  and  the  bleeding  was  arrested  by 
pressure  against  the  transverse  processes,  either  from  above  or  from  below. 
As  a  ligature  could  not  be  applied,  a  plug  of  charpie  of  the  size  of  a  pea, 
soaked  in  solution  of  perchloride  of  iron,  was  introduced  between  the 
transverse  processes,  and  left  there  as  soon  as  it  had  been  ascertained  that 
the  bleeding  was  suppressed.  The  external  wound,  having  been  closed  by 
sutures,  was  covered  with  charpie  dipped  hi  carbolized  glycerine,  Lister's 
carbolic  acid  paste  was  applied,  and  the  dressing  was  retained  in  place  by 
a  bandage.  The  head  was  kept  fixed  by  a  stiff  collar.  The  plug  in  the 
deep  part  of  the  wound  was  removed  on  the  fourth  day  after  the  operation, 
partly  by  means  of  a  stream  of  water,  partly  by  forceps  ;  no  bleeding  fol- 
lowed. Excepting  a  slight  attack  of  erysipelas,  the  patient  progressed 
steadily  toward  recovery,  and  was  discharged  cured  a  little  more  than  five 
weeks  after  the  operation. 

"  But  in  order  to  secure  the  success  of  this  operation  of  plugging  the 
vertebral  artery,  it  is  essential  that  the  bleeding  point  shall  be  exposed  to 
view,  that  the  plug  shall  be  placed  exactly  in  the  open  canal  of  the  vessel, 
which  it  must  completely  fill,  and  that  the  patient's  head  shall  be  held 
fixed,  and  the  neck  immovable,  by  a  stiff  collar." 

Internal  Jugular  Vein. — Wounds  of  this  vessel,  when  treated  by  expos- 
ure of  the  vessel  and  the  application  of  a  ligature  above  and  below  the 
wound,  result  happily  in  a  great  majority  of  cases.  The  free  collateral 
circulation,  through  the  intracranial  venous  sinuses,  the  superficial  veins  of 
the  head  and  neck,  and  the  sinuses  of  the  spinal  canal,  prevent  serious  dis- 
comfort from  being  experienced  by  the  obliteration  of  so  large  a  channel 
as  the  internal  jugular  vein,  when  the  character  of  the  wound  renders  such 
a  proceeding  necessary.  Lateral  wounds  of  this  vessel  should  be  closed 
by  the  lateral  ligature,  if  the  wound  is  small ;  by  lateral  suture,  if  the 
wound  is  long.  The  advantages  of  this  procedure  are  that  it  may  be  more 
quickly  done  ;  it  demands  less  extensive  dissection  and  disturbance  of  the 
neighboring  tissues ;  it  increases  the  prospects  of  obtaining  union  through- 
out the  wound  by  first  intention  ;  and,  finally,  it  preserves  intact  the  func- 
tion of  the  vessel. 

Of  the  thirteen  cases  of  lateral  closure  (12  by  ligature  and  1  by  forci- 
pressure)  of  the  internal  jugular  vein  included  in  the  statistics  of  Braun, 
before  referred  to  (p.  296),  there  were  ten  recoveries,  in  one  of  which,  how- 
ever, the  ligature  slipped  off  and  other  means  were  then  resorted  to. 


340  THE   TREATMENT    OF    WOUNDS. 

There  were  three  deaths  from  secondary  haemorrhage.  In  addition  to 
these  cases,  Dr.  Parkes  of  Chicago,1  has  reported  three  cases  of  lateral 
ligation  of  wounds  of  the  internal  jugular  vein,  followed  by  recovery  in 
each  case.  In  one  of  these  cases  the  constriction  of  the  calibre  of  the 
vessel  caused  by  the  ligature  amounted  to  one-third,  and  in  another  to  one- 
half  its  extent.  No  untoward  symptoms  followed  in  either  case. 

Dr.  Allis,  of  Philadelphia,  reported,1  also,  a  case  in  which  he  had 
applied  a  lateral  ligature  to  the  internal  jugular  vein  on  account  of  a 
Avound  inflicted  in  it  during  the  removal  of  a  tumor  from  beneath  the 
sterno-cleido-mastoid  muscle.  The  recovery  was  rapid  and  permanent. 

Dr.  Gerster,  of  New  York,5  in  a  case  in  which  a  long  longitudinal  slit 
was  made  in  the  internal  jugular  vein,  during  the  removal  of  a  multiple 
lymphoma  of  the  neck,  succeeded  in  closing  the  rent  by  the  application 
laterally  of  a  row  of  catgut  ligatures.  Primary  union  followed  the  opera- 
tion. 

Dr.  Lange,  of  New  York,2  applied  a  lateral  ligature,  of  antiseptic  silk, 
to  a  wound  of  the  internal  jugular  vein,  accidentally  inflicted  in  an  attempt 
to  tie  the  common  carotid  artery  for  secondary  haemorrhage.  Recovery 
took  place. 

Lidell  reports  *  another  successful  case,  in  which,  the  internal  jugular 
vein  having  been  punctured  while  a  deep-seated  tumor  of  the  neck  was 
being  dissected  out,  the  margins  of  the  puncture  were  drawn  together 
and  raised  up  by  a  Listen's  forceps,  and  a  ligature  was  tied  around  them 
on  the  side  of  the  vessel. 

Dr.  J.  E.  Pilcher's  successful  case  of  lateral  forcipressure,  reported  in 
Chapter  XVII.  (p.  292),  should  also  be  recalled  in  this  connection.  These 
eight  recent  attempts  at  securing  lateral  closure  of  a  wound  of  the  internal 
jugular  vein  were  all  attended  with  success,  and  serve  to  demonstrate  the 
feasibility  of  the  practice. 

The  chief  source  of  danger,  which  may  threaten  the  success  of  an  at- 
tempt to  secure  lateral  closure  of  a  wound  of  this  vein  is  the  normal 
lateral  pressure  of  the  column  of  blood  in  the  vessel ;  whenever  the  head 
is  elevated,  whenever  the  free  entrance  of  the  blood  into  the  thoracic  ves- 

1  Proceedings  of  the  Philadelphia  County  Medical  Society,  meeting  of  March  8, 
1882,  in  the  Philad.  Med.  Times,  July,  1882. 

*  Proceedings  of  the  New  York  Surgical  Society,  meeting  of  Feb.  27,  1883.  Medi- 
cal News,  Phila.,  1883.  xlii.,  278. 

3  International  Encyclopaedia  of  Surgery,  iii.,  199. 


WOUNDS  OF  THE  THORAX.  341 

sels  is  impeded,  as  in  coughing  or  straining  at  stool,  this  normal  pi-essure 
is  intensified.  The  contraction  of  the  muscles  of  deglutition,  and  of  the 
muscles  which  cross  it  lower  in  the  neck — the  platysma,  the  sterno- 
cleido-mastoid,  and  the  omo-hyoid — may  also  affect  the  freedom  with 
which  the  current  through  the  vein  shall  pass. 

After  any  wound  of  the  internal  jugular  vein,  and  especially  in  those 
instances  in  which  a  lateral  ligature  has  been  applied,  the  recumbent 
position  must  be  maintained  until  firm  union  of  the  wound  in  the  vessel 
has  taken  place.  Ail  movements  of  the  neck  must  be  restrained  by  the 
mass  and  the  stiffness  of  the  external  dressings  applied  to  the  wound. 
Immobilization  and  compression,  as  far  as  practicable,  should  be  secured. 

The  material  used  for  all  ligatures  of  the  internal  jugular  vein  should 
be  aseptic,  and  the  treatment  of  the  wound  should  be  scrupulously  anti- 
septic, that,  if  possible,  primary  union  of  the  wound  may  be  secured. 

Lateral  ligature  of  this  vessel  should  be  attempted  only  when  aseptic 
thread,  catgut  or  silk,  is  obtainable  and  the  subsequent  course  of  the 
wound  can  be  kept  aseptic.  In  none  of  the  recorded  cases  has  secondary 
haemorrhage  or  other  accident  disturbed  the  course  of  the  healing  after  lat- 
eral ligation  when  these  precautions  of  antisepsis  have  been  observed.  The 
danger  of  secondary  haemorrhage  should  deter  from  resort  to  lateral  liga- 
tion of  this  vessel  when  ordinary  ligatures  are  used  and  the  wound  cannot 
be  kept  from  septic  contamination.  When  secondary  haemorrhage  occurs, 
it  must  be  treated  by  exposure  of  the  vessel  and  the  application  of  a  liga- 
ture both  above  and  below  the  bleeding  aperture. 

WOUNDS   OF   THE  THORAX. 

Wounds  of  the  thorax  are  subject  to  the  same  general  divisions  as 
those  affecting  other  parts — they  may  be  incised,  punctured,  or  gunshot, 
contused  or  lacerated — and  are  subject  to  such  variations  in  treatment  aa 
may  be  appropriate  to  these  varieties.  More  important,  however,  in  this 
region  is  the  division  into  non-penetrating  and  penetrating  wounds.  The 
former  class  includes  those  wounds  which  affect  the  thoracic  wall  only, 
without  opening  the  pleural  sac.  The  latter  includes  all  those  which 
involve  injury  to  the  contents  of  the  thorax. 

NON-PENETRATING  WOUNDS. — Superficial  wounds  of  the  thorax  present 
no  peculiarities  requiring  special  consideration,  except  the  difficulty  which 
attends  efforts  to  secure  the  advantages  of  immobility  in  their  treatment, 


342  THE   TKEATMENT    OF    WOUNDS. 

on  account  of  the  continual  rising  and  falling  of  the  chest-walls  in  respira- 
tion. As  the  result,  when  union  by  first  intention  fails  to  be  secured,  the 
healing  by  granulation  is  apt  to  be  retarded  in  its  course.  This  mobility 
of  the  thoracic  walls  may  be  restricted  by  surrounding  the  thorax  with  a 
broad,  tightly  drawn  bandage,  which  will  restrain  the  movements  of  the 
ribs,  and  make  the  breathing  more  abdominal  in  its  character. 

Deeper  wounds  of  the  thoracic  wall  may  involve  fracture  of  the  ribs  or 
costal  cartilages,  and  wounds  of  the  internal  mammary  and  intercostal 
arteries.  The  methods  detailed  in  Chapter  XV.  should  be  applied  to  the 
treatment  of  wounds  complicated  by  bone  injuries. 

Wounda  of  the  arteries  should  be  treated,  whenever  practicable,  by 
their  exposure,  and  the  application  of  a  ligature  to  both  the  proximal  and 
distal  ends  of  the  vessel  The  external  wound  should  be  enlarged  by  in- 
cision, if  necessary,  until  the  bleeding  point  is  brought  into  view.  Certain 
special  points  in  connection  with  each  of  these  arteries  require  mention. 

Internal  Mammary  Artery. — The  results  of  wounds  of  this  vessel  have 
been  disastrous  in  most  of  the  recorded  cases.  Of  the  five  cases  in  which 
it  was  distinctly  recognized,  and  treatment  attempted,  during  the  -War  of 
the  Rebellion,  all  terminated  fatally.  When — as  is  most  frequently  the 
case — the  wound  which  has  severed  this  vessel  has  also  penetrated  more 
deeply  and  has  opened  the  anterior  mediastinum,  the  cavity  of  the  peri- 
cardium or  of  the  pleura,  the  dangers  of  intra-thoracic  and  concealed 
haemorrhage  are  added.  According  to  Tourdes,1  as  quoted  by  the  sur- 
gical historian  of  the  War  of  the  Rebellion,  more  than  hah*  the  cases  are 
accompanied  by  section  of  the  costal  cartilages,  and  this  section  always 
occurs  when  the  vessel  is  wounded  below  the  fourth  rib  by  an  incised 
wound.  There  may  be  external  haemorrhage,  and  internal,  into  the 
anterior  mediastinum,  into  the  pleural  cavity  and  into  the  pericardium. 
The  diagnosis  may  be  very  difficult,  for  the  signs  of  intra-thoracic  extrava- 
sation are  often  equivocal  In  continuation,  Otis  quotes  the  observations 
of  Nelaton,"  that  if  the  haemorrhage  is  suspended  at  the  time  of  examina- 
tion, anatomical  considerations  may  afford  presumptive  evidence,  and  that 
every  deep  wound  near  the  margin  of  the  sternum,  from  the  first  to  the 
seventh  rib,  should  be  viewed  with  suspicion.  External  arterial  haemor- 
rhage decides  the  point ;  but  this  sign  is  often  absent.  The  diagnosis  may 

1  Des  blessurea  de  Fartere  mammaire  interne  sous  le  point  de  vue  medico-legal,  Paris, 
1849,  p.  41. 

*  Element  de  Pathologie  cftirurgicale,  t.  iii.,  p.  450. 


WOUNDS    OF   INTERNAL   MAMMARY   ARTERY.  343 

be  complicated  by  bleeding  from  wounded  lung,  and  the  internal  haemor- 
rhage then  affords  no  decisive  sign,  the  position  of  the  wound  alone  sug- 
gesting the  presumption  that  the  internal  mammary  artery  is  interested. 
The  vessel  is  often  of  sufficient  calibre  to  furnish  blood  very  freely,  and 
death  may  result  either  from  the  profusion  of  the  bleeding  or  from 
asphyxia  from  haemothorax.  If  the  blood  passes  into  the  pericardium,  the 
heart's  movement  is  impeded  and  soon  arrested  ;  if  it  enters  the  pleural 
cavity  or  mediastinum,  there  is  room  for  mortal  haemorrhage  ;  and  if  the 
patient  escape  these  primary  accidents  he  is  exposed  to  those  of  putrid  de- 
composition of  the  extravasated  blood. ' 

In  all  cases,  therefore,  of  deep  wounds  of  that  portion  of  the  anterior 
wall  of  the  thorax,  in  which  the  internal  mammary  artery  runs,  its  exter- 
nal enlargement,  sufficiently  to  permit  definite  determination  of  the  fact 
whether  this  vessel  is  wounded  or  not,  should  be  made.  The  enlargement 
of  the  wound  should  be  made  by  incisions  directed  slightly  obliquely  to 
the  axis  of  the  body,  from  above  downward,  and  from  without  inward,  so 
that  the  centre  of  the  incision  should  be  three  or  four  lines  external  to  the 
margin  of  the  sternum,  and  •  in  the  original  wound.  All  the  superficial 
structures  should  be  freely  incised,  so  as  to  fully  expose  the  wounded 
intercostal  space.  The  anatomical  difficulties  which  may  embarrass  the 
exposure  of  the  vessel  now  present  themselves.  They  consist  of  the  shel- 
ter which  the  costal  cartilages  and  the  adjacent  border  of  the  sternum  give 
to  the  vessel.  In  the  upper  three  or  four  intercostal  spaces,  sufficient 
room  between  the  cartilages  may  be  found  for  the  debridement  needed  to 
expose  the  vessel ;  in  the  lower  spaces,  resection  of  a  portion  of  one  or 
more  of  the  cartilages  may  be  needed,  and  should  be  promptly  and  boldly 
done.  The  primary  and  imperative  indication  is  to  expose  the  bleeding 
vessel,  and  no  superficial  structure  should  be  permitted  to  arrest  the  effort 
till  its  end  has  been  accomplished. 

The  task  is  more  difficult  in  cases  of  secondary  haemorrhage,  where  the 
adjacent  soft  tissues  have  become  swollen  and  infiltrated,  and  the  vessel 
lacerated  and  displaced.  The  attempt  to  secure  it  in  the  wound,  however, 
should  be  made  ;  failing  in  that,  the  tampon  might  be  resorted  to,  after  the 
plan  of  Desault.  This  consists  in  placing  over  the  wound  a  fine  compress, 
four  or  five  inches  square.  The  centre  of  this  is  pressed  through  the 
wound  so  as  to  form  a  glove-finger-like  sac  projecting  into  the  thoracic 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Part  I. ,  vol.  ii. ,  Sur- 
gical History,  p.  525. 


344  THE   TREATMENT    OF    WOUNDS. 

cavity.  This  is  then  stuffed  firmly  with  lint ;  the  angles  of  the  compress 
on  the  outside  are  then  brought  together,  and  the  intra- thoracic  pad  or 
ball  of  lint  is  drawn  gently  outward,  and  made  to  compress  the  wounded 
vessel  against  the  sternum  or  ribs.  To  keep  the  pad  in  place,  the  com- 
press may  be  tied  like  a  purse,  and  the  ligature  secured  around  a  roller  or 
other  convenient  cylinder.  According  to  Otis,  this  is  the  best  resource,  if 
the  attempt  to  ligate  the  vessel  fails.  The  hazard  of  exciting  inflammation 
in  the  pleura  and  lung  is  less  to  be  dreaded  than  the  danger  of  hsemo- 
thorax.  The  risks  of  exciting  inflammation  of  the  intra-thoracic  parts 
would  be  lessened  by  using  antiseptic  materials  in  making  this  tampon, 
the  outer  part  being  made  of  antiseptic  gauze,  and  antiseptic  cotton,  jute, 
or  gauze  being  used  for  the  stuffing. 

Intercostal  Artery. — In  recent  wounds,  properly  directed  attempts  to 
expose  the  intercostal  artery  by  enlarging  the  wound  should  meet  with 
no  insurmountable  difficulty.  As  the  location  of  the  wound  recedes  from, 
the  sternum,  the  trouble  which  may  be  experienced  will  be  likely  to  be- 
come increased,  owing  to  the  greater  thickness  of  the  external  soft  parts, 
the  greater  protection  exercised  by  the  projecting  edge  of  the  rib  under- 
neath which  it  runs,  and  the  larger  size  of  the  vessel,  and  the  consequent 
more  profuse  bleeding  from  it  In  the  later  history  of  a  wound,  when 
secondary  haemorrhage  from  the  artery  requires  to  be  arrested,  the  swol- 
len and  infiltrated  condition  of  the  parts  would  still  further  increase  the 
difficulties  of  exposing  it  and  ligating  it  directly.  In  such  case,  should 
efforts  at  direct  ligation  prove  unsatisfactory,  the  tampon  of  Desault  might 
be  resorted  to,  as  described  in  connection  with  the  internal  mammary 
artery.  If  this  should  prove  inadequate,  mediate  ligation  of  the  artery,  by 
including  it  in  the  loop  of  a  ligature  thrown  around  the  adjacent  rib,  may 
be  done.  This  method  of  securing  this  artery  is  described  as  follows  by 
Agnew, '  who  has  invented  an  instrument  for  facilitating  its  practice  :  "  A 
strong,  sharply  curved  needle,  with  a  blunt  point  having  in  it  an  eye  for 
the  thread,  should  be  taken.  Having  introduced  a  strong  thread  (silk, 
catgut,  or  silver)  through  this  eye,  prolong  the  wound  a  little  posteriorly, 
and,  dipping  the  point  of  the  needle  under  the  lower  edge  of  the  rib,  fol- 
low closely  its  inner  surface,  and,  by  depressing  the  handle  of  the  instru- 
ment, make  the  point  present,  covered  by  the  integuments,  at  the  upper 
margin  of  the  rib.  An  incision  should  now  be  made  so  as  to  uncover  the 
point  of  the  instrument  and  enable  the  operator  to  remove  the  thread  from 

1  The  Principles  and  Practice  of  Surgery,  1878,  i,  329. 


PENETRATING    WOUNDS    OF    THORAX.  345 

its  eye,  after  which  the  instrument  should  be  withdrawn.  The  ends  may 
be  disposed  of  by  tying  them  together  over  a  roll  of  lint,  or  by  passing 
them  through  the  openings  in  a  bone  button,  and  then  securing  the  knot 
Another  plan  of  dealing  with  the  ligature,  after  thus  encircling  the  rib,  ia 
to  pass  the  end  which  was  removed  from  the  eye  of  the  instrument  through 
an  ordinary  good-sized  needle,  slightly  curved  at  its  extremity,  and,  rein- 
serting it  at  the  puncture  made  at  the  upper  part  of  the  rib,  carry  it  be- 
tween the  integuments  and  the  external  surface  of  the  ribs,  bringing  it 
out  at  the  original  wound.  This,  which  is  quite  easily  accomplished,  con- 
stitutes a  subcutaneous  ligation  without  the  inclusion  of  soft  parts.  The 
upper  puncture  should  then  be  closed  with  an  adhesive  strip.  Ligatures 
applied  in  this  way  unavoidably  compress  artery,  vein,  and  nerve. 

PENETRATING  WOUNDS. — Wounds  which  pierce  the  pleural  sac  may  either 
simply  open  the  pleural  cavity  or  may  involve  the  organs  contained  within 
the  chest  to  a  varying  extent.  The  most  numerous  class  of  penetrating 
wounds  of  the  chest  are  gunshot  wounds.  Next  to  these  in  frequency  are 
punctured  and  incised  wounds. 

The  prognosis  of  penetrating  gunshot  wounds  is  very  grave.  Out  of 
8,715  cases  tabulated  in  the  "Medical  and  Surgical  History  of  the  War 
of  the  Rebellion "  (Part  I,  vol.  ii.,  p.  606),  5,260—62.6  per  cent.— died. 
Out  of  1,609  cases  collected  from  various  authors,  and  tabulated  in  the 
same  history,  1,049 — 65.2  per  cent. — died.  The  course  of  incised  and 
punctured  wounds  is  much  more  favorable.  Of  291  cases  reported  by 
Albanese,1  of  Palermo,  only  24 — $.2  per  cent. — resulted  fatally,  8  of  which 
were  wounds  of  the  heart,  and  4  wounds  complicated  with  wounds  of  the 
abdomen,  the  peritonitis  from  which  caused  the  fatal  result.  The  great 
fatality  of  chest- wounds  depends  upon  the  vital  importance  of  the  organ 
wounded  and  the  extent  of  the  wound.  Of  the  iutra-thoracic  organs, 
wounds  of  which  may  be  in  any  degree  affected  by  treatment  directed 
especially  to  them  in  any  case,  the  lungs  and  the  pleura  demand  most 
extended  notice.  Brief  notice  must  be  given  to  possible  opportunities 
that  may  present  for  interference  in  rare  cases  of  heart-Avound.  Wounds 
of  the  thoracic  portion  of  the  oesophagus,  of  the  thoracic  duct,  and  of  the 
nerve-trunks  that  descend  through  the  thorax  are  beyond  the  reach  of  the 
surgeon.  Wounds  of  the  great  blood-vessels  are  quickly  and  hopelessly 
mortal.  Examination  of  the  opportunities  for  treatment  presented  by  the 
heart  and  its  sac,  by  the  lungs,  and  by  the  pleurae,  will  first  be  made,  after 

1  Transactions  International  Medical  Congress.  London,  1881,  ii.,  438. 


346  THE   TREATMENT    OF    WOUNDS. 

which  the  general  cares  demanded  by  penetrating  chest-wounds,  as  a 
whole,  will  be  considered. 

Heart  and  Pericardium. — Not  every  wound  of  the  heart  results  fatally. 
The  statistics  of  Fischer,1  for  which  we  are  indebted  to  quotation  by  Otis 
(op.  citat,  p.  530),  state  that  out  of  452  cases  analyzed,  75 — 16.3  per 
cent. — recovered.  Many  instances  are  recorded  of  death  occurring  some 
hours  or  days  after  the  reception  of  a  wound  of  the  heart  by  a  gradual 
leakage  from  it,  the  blood  escaping  into  the  pericardium,  and  also,  in  some 
cases,  into  the  pleural  cavity  through  a  pericardia!  wound,  and  producing 
death  either  by  the  loss  of  blood,  or  by  the  embarrassment  to  the  heart 
occasioned  by  the  accumulating  effusion  in  its  investing  sac.  If  such 
cases  could  be  recognized  before  death,  with  any  degree  of  certainty,  their 
otherwise  hopeless  course  would  justify  an  exsection  of  the  overlying  car- 
tilages, an  incision  into  the  pericardium,  the  evacuation  of  the  effused 
blood,  and  an  attempt  to  suture  the  rent  in  the  heart- wall.  That  the  peri- 
cardial  cavity  can  be  opened  for  a  short  time  with  impunity  in  the  human 
being,  Koenig's  case  of  excision  of  the  sternum,11  in  the  course  of  which 
both  pleural  cavities  and  the  pericardium  were  opened  into,  has  demon- 
strated. In  this  case  the  openings  were  at  once  occluded  with  antiseptic 
gauze.  The  dressing  was  not  disturbed  for  twelve  days.  Ultimate  recov- 
ery was  secured.  Block  *  has  farther  shown  that  in  dogs,  not  only  can  the 
pericardial  cavity  be  opened  with  impunity,  but  the  heart  may  be  seized  at 
its  apex,  and  held  still  sufficiently  long  for  the  introduction  of  a  suture, 
and  still  have  it  resume  its  pulsations.  It  is  not  impossible  that  heart- 
suture  may  yet  be  successfully  performed  in  the  human  subject. 

Lungs. — The  wounded  lung  will  collapse  more  or  less  closely,  accord- 
ing to  the  size  of  the  aperture  in  the  thoracic  wall,  and  the  freedom  with 
which  air  can  pass  into  the  cavity  of  the  chest  through  it.  In  rare  in- 
stances protrusion  of  a  portion  of  the  lung  through  the  external  wound 
has  taken  place.  The  lung-wound  may  bleed,  may  become  inflamed,  may 
be  complicated  by  the  retention  within  it  of  a  foreign  body.  The  bleed- 
ing from  a  lung-wound  will  exhibit  itself  both  by  a  bloody  expectoration, 
and  by  effusion  into  the  pleural  cavity.  Its  arrest  must  be  procured  by 
general  measures ;  absolute  quiet  and  silence  ;  ice,  swallowed,  and  also 

1  Die  Wunden  des  Herzens  und  det  Herzbeutela.  Archit  fur  klinixche  Chirurgie, 
ir.,571. 

*  Attgemeine  Winner  medicinische  Zeitung,  September  25,  1882. 
1  Gazette  Medicate  de  Strasbourg,  October  18,  1882. 


WOUNDS    OP   THE   LUNGS.  347 

applied  to  the  surface  of  the  chest ;  ergotine,  hypodermically  adminis- 
tered ;  opium  ;  heat  and  counter-irritants  to  the  extremities.  The  man- 
agement of  accumulations  of  blood  in  the  pleura!  cavity  will  be  considered 
in  another  connection.  Traumatic  pneumonia  does  not  involve  large  por- 
tions of  the  lung  structure,  as  in  the  idiopathic  variety,  but  is  limited  to 
the  vicinity  of  the  wound  track.  The  inflammatory  exudation  may  be 
absorbed,  may  be  discharged  through  the  bronchial  tubes,  or  may  accu- 
mulate in  the  cavity  of  the  pleura.  From  the  latter  cavity  they  will  need 
to  be  evacuated  by  incision  and  drainage. 

Foreign  bodies  embedded  in  the  substance  of  the  lung  are  not  to  be 
searched  for,  but  left  to  their  spontaneous  course.  Should  the  patient 
survive,  and  continued  ill  effects  be  experienced  from  the  foreign  body,  the 
propriety  of  exploratory  operation,  and  of  resection  of  a  portion  of  the 
lung  may  yet  become  a  matter  of  consideration.  The  experiments  of 
Block,1  upon  animals,  in  which  recovery  and  survival,  in  apparently  good 
health,  was  secured  after  the  removal  of  from  one  to  four  pulmonary  lobes, 
are  sufficiently  encouraging  to  suggest  the  hope  that  such  an  operation 
may  be  proven  to  be  available  for  the  relief  of  otherwise  hopeless  cases  of 
prolonged  suppuration  and  irritation  from  the  retention  in  a  lung  of  a  for- 
eign body. 

Hernia  of  the  lung  should  be  treated  by  carefully  cleansing  and  disin- 
fecting the  protrusion,  and,  if  possible,  returning  it  into  the  thoracic 
cavity,  enlarging  as  much  as  may  seem  prudent  the  original  wound,  in 
order  to  favor  the  return.  According  to  Otis  (op.  citat.,  ii.,  518),  there 
is,  however,  but  a  single  instance  of  successful  reduction  of  a  traumatic 
pneumocele  without  previous  ligation  of  the  tumor  at  its  base  and  excision 
of  the  distal  portion.  If  the  first  attempt  to  reduce  fail,  either  ligation 
and  excision  may  be  done,  or  no  interference  be  attempted  beyond  pro- 
tecting the  protrusion  during  the  course  of  its  becoming  adherent  to  the 
margins  of  the  wound  and  its  ultimate  cicatrization.  In  most  of  the  re- 
corded cases  the  former  has  been  done,  and  without  bad  results.  The 
material  for  the  ligature  should  be  aseptic,  and  the  stump,  after  having 
been  disinfected,  may  be  returned  to  the  pleural  cavity  without  hesitation. 

Pleurce. — By  the  penetration  of  the  pleural  sac,  air  and  blood  enter  its 
cavity ;  air  escaping  again  through  its  external  opening  may  become  dif- 

1  ExperimenteUe*  zur  Lungenresection.  Deutsche  med.  Wochenschrift,  Berlin,  1881, 
vii.,  634-636. 


348  THE   TREATMENT    OF    WOUNDS.      . 

fused  among  the  interstices  of  the  subcutaneous  connective-tissue  ;  and, 
finally,  septic  inflammation  of  the  pleura!  membrane  itself,  with  accumula- 
tion of  inflammatory  products  in  its  cavity,  may  follow. 

In  general  the  mere  fact  of  the  presence  of  air  and  blood  in  the  pleura! 
cavity  does  not  call  for  active  interference  unless  they  accumulate  in  such 
quantity  as  to  embarrass  the  action  of  the  sound  lung.  The  escape  of 
blood  to  such  an  amount  would  be  fatal  from  the  loss  of  blood  alone. 

Hcemothorax. — Signs  of  an  increasing  accumulation  of  blood  in  the 
pleura!  cavity  call  for  a  renewed  examination  of  the  wound  in  the  parietes, 
to  exclude  a  possible  haemorrhage  from  a  superficial  vessel.  If  such  should 
be  found,  it  should  be  secured  by  ligature  at  once.  If  not,  the  opening 
into  the  thorax  should  be  made  sufficiently  free,  so  that  the  blood  being 
effused  into  its  cavity  may  escape  externally,  while  the  general  measures 
for  arresting  the  haemorrhage,  which  have  been  referred  to  in  connection 
with  bleeding  from  the  lungs,  should  be  adopted.  Effusions  of  blood 
which  have  been  retained  in  the  pleura!  cavity  and  have  undergone  decom- 
position are  to  be  removed  by  incisions  through  the  wall  of  the  chest,  and 
by  antiseptic  irrigation. 

Pneumothorax. — The  relief  of  troublesome  pneumothorax  is  to  be  ac- 
complished by  dilating  the  external  wound  so  that  the  escape  of  air  from 
the  wounded  cavity  may  meet  with  no  obstruction. 

Emphysema,  rare  after  gunshot  wounds,  and  more  frequent  after 
oblique  stab  wounds,  is  due  to  a  want  of  parallelism  between  the  superficial 
and  the  deep  portions  of  the  parietal  wound.  The  wound  should  be  en- 
larged sufficiently  to  make  the  whole  track  free  and  direct  The  swollen 
tissues  should  be  compressed  by  a  bandage ;  punctures  and  scarifications 
may  be  made  if  needed,  but  will  rarely  be  required. 

Empycema  and  Hydrothorax. — Accumulations  of  fluid,  the  results  of 
traumatic  pleurisy,  require  thoracentesis  for  their  removal  Simple  se- 
rous exudation  may  be  removed  by  aspiration ;  sero-purulent  and  sanguineo- 
purulent  collections  should  be  evacuated  by  free  incision  of  the  thoracic 
wall,  irrigation  with  antiseptic  lotions,  and  drainage  until  obliteration  of 
the  purulent  cavity  is  accomplished.  Exsection  of  a  portion  of  a  rib  may 
be  done,  if  necessary  to  give  the  required  freedom  to  the  opening.  The 
opening  should  be  free  enough  to  admit  a  finger  easily,  and  to  permit  the 
escape  of  any  fibrinous  shreds,  masses  of  gangrenous  tissue,  or  foreign 
bodies  that  may  be  loose  in  the  pleura!  cavity.  In  resecting  a  rib,  the 
method  of  procedure  should  be  as  follows :  Make  an  incision  for  two  inches 


TREATMENT    OF    EMPY^EMA.  349 

or  more  directly  over  the  rib  selected,  and  join  this,  at  its  mid  point,  by 
another  an  inch  long,  carried  downward  at  right  angles  to  it  This  should 
be  deepened  until  the  rib  has  been  completely  exposed  throughout  the 
length  of  the  first  incision,  and  then  the  periosteum  divided  in  a  direction 
parallel  to  the  long  axis  of  the  bone.  Then  raise  it  by  means  of  a  perios- 
teum-elevator, which  is  also  passed  beneath  the  rib  so  as  to  separate  it 
from  the  deep  surface,  a  manoeuvre  which  is  rapidly  and  easily  accom- 
plished. A  curved  elevator  is  then  slipped  completely  beneath  the  rib 
which  is  thus  raised  slightly  from  those  immediately  above  and  below 
it,  and  a  piece,  from  one  to  two  inches  long,  is  removed  either  by  cut- 
ting pliers  alone,  or  after  first  dividing  the  bone  half  through  with  a  small 
saw.  This  is  all  completed  before  the  pleura,  or  indeed  the  deep  part  of 
the  periosteum,  are  in  any  way  interfered  with.  The  soft  parts  being  held 
aside  with  hooks,  the  pleura  is  then  incised  at  leisure,  and  the  opening  is 
enlarged  by  expanding  the  blades  of  a  pair  of  dressing  forceps.  The  risk 
of  wounding  the  intercostal  artery  is  thus  absolutely  avoided,  and  if  any 
vessel  be  divided,  either  in  the  superficial  or  the  deeper  structures,  it  is 
easily  seen  and  readily  secured.  Such  an  opening  will  admit  the  finger,  if 
it  be  thought  advisable  to  introduce  it,  and  in  the  subsequent  progress  of 
the  case  the  removal  of  the  portion  of  the  rib  leads  to  no  inconvenience. 
Antiseptic  dressing  of  the  drainage-wound  (Chapter  X. )  should  be  caref  ully 
performed,  as  directed  in  the  next  section  for  the  original  wound. 

An  efficient  drainage-tube  may  be  readily  improvised  in  the  following 
manner : '  Take  a  piece  of  pure  India-rubber  sheeting,  T12  inch  thick  and 
about  1£  or  2  inches  square,  and  cut  a  round  hole  in  its  centre.  Then 
take  a  piece  of  tubing,  of  the  size  required,  and  without  holes,  and  of  a 
length  merely  sufficient  to  project  into  the  chest  cavity,  being  from  1£  to 
2j  inches  long — according  to  the  thickness  of  the  chest  wall.  Split  this  at 
one  end  into  four  pieces,  which  are  then  drawn  through  the  hole  in  the 
flat  piece  of  rubber,  turned  down  upon  it,  and  fixed  in  position  by  stitches 
of  fine  silver  wire.  The  completed  tube  is  shown  in  Fig.  105.  Such  a 
tube  will  adapt  itself  to  a  sinus  leading  in  any  direction,  and  will  require 
no  special  manoeuvres  to  prevent  its  slipping  into  the  chest  ;  it  may  be  left 
beneath  an  antiseptic  dressing  for  many  days  at  a  time,  in  confidence  that 
it  will  work  well  all  the  time. 

General  Eesume. — If  the  external  wound  is  small,   with  no  or  only 

1  R.  J.  Godlee,  The  Treatment  of  Empyema.  Annals  of  Anatomy  and  Surgery, 
July,  1883,  viii,  13. 


350 


THE    TREATMENT    OF    WOUNDS. 


slight  splintering  of  the  bones,  and  is  adapted  for  primary  closure,  imme- 
diate antiseptic  occlusion  should  be  done. 

If  the  wound  is  extensive,  not  suitable  for  primary  closure,  and  compli- 
cated by  an  extensive  bone-splintering,  it  should  be  enlarged  and  carefully 

cleansed  by  the  removal  of  the  splint- 
ers of  bone,  tissue-shreds,  clots,  or 
foreign  substances  that  may  be  en- 
tangled in  it ;  sufficient  counter-open- 
ings should  be  made  to  afford  effective 
drainage,  and  thorough  disinfection 
of  the  wound  and  its  surroundings 
should  be  made.  Then  thick  and  ex- 
tensive layers  of  antiseptic  protective 
material  (Chapter  X.)  should  be  ap- 
plied, with  adequate  drains  in  the 
wound  and  in  the  counter-openings. 
The  whole  should  be  secured  in  place 
with  bandages  applied  so  as  to  strong- 
ly compress  the  thorax  and  restrict  its 
movements.  To  prevent  the  access  of  air  under  the  edges  of  the  dressings, 
an  elastic  bandage  should  be  carried  around  its  upper  and  lower  borders  ; 
to  prevent  slipping  of  the  dressings  up  or  down,  a  muslin  bandage  should 
be  carried  once  or  twice  over  one  shoulder  and  down  under  the  perineum, 
and  up  over  the  shoulder  again,  and  secured  by  pins  to  the  upper  and 
lower  parts  of  the  dressing,  in  front  and  behind.  The  antiseptic  dressings 
should  cover  the  whole  width  of  the  thorax,  from  neck  to  navel. 

Changes  of  dressing  should  be  made  as  rarely  as  possible.  Should 
occlusion  not  be  successful  in  preventing  copious  suppuration  in  the 
wound-track,  more  frequent  changes  of  the  dressings  will  be  required. 

In  the  primary  cleansing  of  the  wound,  if  foreign  bodies  present  them- 
selves, they  should  be  removed,  but  no  search  by  probing  for  a  foreign 
body  should  be  made. 

The  arrest  of  haemorrhage  will  be  attended  to  as  a  part  of  the  primary 
cleansing  of  the  wound  which  has  been  described. 


Fia  105. — Drainage-Tube  for  use  in  Empyajma. 


CHAPTER  XX. 
WOUNDS  OF  THE  ABDOMEN— OF  THE  PELVIS. 

Non-penetrating  Wounds  ofParietes— Arrest  of  Haemorrhage— Apposition— Penetrating 
Wounds  without  Injury  to  Viscera— The  Peritoneal  Wound— Protrusion  of  Vis- 
cera— Intestine — Oraentura — Other  Viscera — Penetrating  Wounds  with  Injury  to 
Viscera — Exploration  of  Abdomen — Diagnosis  Positive — Diagnosis  Presumptive — 
Arrest  of  Intraperitoneal  Haemorrhage — Suture  of  Visceral  Wounds — Lembert's 
Suture — Jobert's — Emmert's — Gely'a— Gussenbauer's — Czerny's — The  Continuous 
Intestinal  Suture — Circular  Invagination  Suture — Primary  Cleansing  of  Perito- 
neal Cavity — Drainage — Peritonitis  and  Septicaemia —  Wounds  of  the  Bladder — 
External  Incisions — Laparotomy — Suture  of  Bladder — Catheterization —  Wounds 
of  Anus  and  Rectum. 

WOUNDS  of  the  abdomen  may  involve  simply  the  abdominal  wall,  without 
penetration  of  the  peritoneal  sac  ;  they  may  penetrate  the  peritoneal  sac 
without  wounding  any  abdominal  viscera  ;  they  may  involve  wounds  of 
any  of  the  viscera.  Each  class  presents  certain  features  in  treatment 
which  require  special  consideration. 

NON-PENETRATING  WOUNDS  OF  THE  PARIETES. 

ABREST  OP  HEMORRHAGE. — When  arterial  bleeding  is  present,  the  gen- 
eral rule,  that  the  bleeding  vessel  shall  be  exposed  in  the  wound,  and  a 
proximal  and  distal  ligature  be  applied  to  the  divided  ends,  is  imperative. 
The  internal  epigastric,  the  internal  mammary,  arid  the  internal  circumflex 
iliac  arteries,  when  wounded,  may  retract  within  the  muscles  among  which 
they  lie,  and  cause  trouble  in  securing  them  ;  should  attempts  be  made 
by  compression  and  styptics  to  control  the  bleeding,  extensive  interstitial 
extravasation  would  be  endangered,  entailing  suppuration  and  sloughing, 
even  though  the  haemorrhage  be  primarily  checked.  Punctured  wounds 
of  these  vessels  are  liable  to  the  same  danger  of  hidden  extravasation. 
In  cases  of  penetrating  wounds,  the  blood  may  flow  into  the  peritoneal 
cavity  and  be  concealed.  In  case  of  a  deep  wound  of  the  abdominal  pari- 


852  THE    TREATMENT    OF    WOUNDS. 

etes,  involving  the  muscles,  the  surgeon  should  be  sure  that  perfect  and 
definite  haemostasis  has  been  secured  before  the  wound  be  closed.  Every 
arterial  branch  that  bleeds  should  be  tied,  and  double  ligature  of  the 
larger  trunks  must  not  be  neglected. 

Should  extravasation  of  blood  among  the  intermuscular  or  interapo- 
neurotic  spaces  have  already  taken  place,  the  clots  should  be  removed  as 
far  as  possible,  and  thorough  disinfection  of  the  parts  be  made.  Should 
the  case  have  proceeded  to  the  point  of  clot-decomposition  and  suppura- 
tion, free  incisions,  antiseptic  irrigations,  and  drainage  should  at  once  be 
made. 

APPOSITION. — Wounds  in  the  abdominal  parietes  require  that  careful 
apposition  of  all  the  divided  structures  should  be  secured,  to  prevent  pre- 
mature weakening  of  its  structure.  Otis  remarks,  "Later  experience 
attests  the  utility  of  deep  sutures  ;  it  was  generally  observed  during  the 
late  war  that  ventral  protrusions  were  only  to  be  prevented,  after  ex- 
tended division  of  the  abdominal  walls,  by  exact  coaptation  of  the  divided 
muscular  tissues.  The  quilled  suture  answered  the  best  purpose,  redu- 
cing the  extensible  cellulo-fibrous  cicatrix  to  the  narrowest  dimensions. 
Twice  by  this  means  I  secured  firm  cicatrices,  without  protrusion,  in  ex- 
tensive incised  wounds  in  the  bellies  of  horses,  where  the  difficulty  of 
exact  reunion  is  great."  The  possibility  of  the  regeneration  of  muscular 
fibres,  and  thus  the  ultimate  perfect  restoration  of  the  integrity  of  the 
wounded  part,  is  an  additional  reason  for  great  care  in  securing  coaptation. 
A  position  which  should  relax  the  wounded  structures,  together  with  the 
compression  and  support  of  ample  protective  dressings  and  a  bandage, 
should  not  be  neglected. 


PENETRATING    WOUNDS    OF    ABDOMINAL    WALL   WITHOUT   INJURY   OF 

VISCERA. 

Wounds  which  penetrate  the  peritoneal  cavity,  without  injuring  any 
contained  viscus,  may  not  differ  from  non-penetrating  wounds,  except  in 
the  addition  of  the  wound  in  the  peritoneum ;  they  may  be  complicated  by 
protrusion  through  the  wound  of  some  of  the  abdominal  contents  ;  they 
may  be  complicated  by  the  entrance  of  foreign  matter  or  blood  into  the 
peritoneal  cavity. 

THE  PERITONEAL  WOUND. — This  should  be  closed  by  being  included  in 
the  deep  sutures  introduced  for  the  purpose  of  closing  the  wound  in  gen- 


PENETRATING  WOUNDS  OF  ABDOMEN.         353 

eraL  These  deep  sutures  should  be  inserted  rather  more  than  an  inch 
from  the  border  of  the  wound,  and  should  slope  toward  the  inner  surface, 
yet  so  as  to  include,  upon  either  side,  a  narrow  strip  of  peritoneum.  When 
the  sutures  are  tightened,  the  included  peritoneal  surfaces  are  brought 
into  apposition,  and  adhere  with  great  rapidity.  Whenever  edges  or  sur- 
faces of  peritoneum  are  divided  or  separated,  they  should,  if  possible,  be 
reunited.  Peritoneum  must  be  apposed  to  peritoneum  ;  the  edges  should 
be  inverted  so  that  two  serous  surfaces  shall  be  pressed  together,  the  exact 
opposite  of  the  conditions  required  for  the  union  of  skin  or  mucous  mem- 
brane, union  of  wounds  in  which  is  prevented  by  inversion  of  the  skin  or 
membrane  into  the  wound.  The  reparative  processes  in  the  serous  mem- 
brane of  the  abdomen  are  identical  with  those  described  for  the  intima  of 
blood-vessels.  When  the  peritoneal  margins  of  a  wound  are  brought  and 
held  in  apposition  by  sutures,  the  effused  lymph  quickly  adheres,  fills  up 
the  angle  of  union,  and  may  make  so  smooth  a  surface  as  even  to  render 
undistinguishable  the  line  of  union.  In  wounds  of  the  parietal  peritoneum, 
we  have  the  best  reasons,  clinically,  why  we  should  always  reunite  the 
severed  edge's  of  the  peritoneum.  As  has  been  pointed  out  by  Sims,1  if 
the  edges  of  the  peritoneum  are  not  embraced  in  the  sutures  that  close  the 
abdominal  section,  a  raw  surface  is  left  on  the  inner  face  of  the  wound, 
which  immediately  adheres  to  the  subjacent  parts.  If  it  happens  to  ad- 
here to  the  omentum,  well  and  good  ;  but  if  to  intestine,  the  result  may  or 
may  not  be  fortunate.  For,  if  the  adherent  intestine  happen  to  be  con- 
voluted in  such  a  way  as  to  obstruct  the  bowel,  a  fatal  result  may  follow. 
Sims  relates  that  he  has  seen  three  cases  in  which,  while  the  parietal 
wound  gaped  open  widely,  the  peritoneal  edges  were  firmly  united.  In 
these  cases,  if  the  peritoneum  had  not  been  closed,  there  would  have  been 
no  union  whatever  in  the  line  of  the  abdominal  incision. 

PROTRUSION  OF  VISCERA. — The  viscera  most  frequently  met  with  protrud- 
ing through  wounds  of  the  abdominal  parietes  are  the  small  intestine  and 
the  omentum.  Instances  of  protrusion  of  the  stomach,  liver,  spleen,  kid- 
neys, and  bladder  have  been  noted.  Many  instances  of  recovery  from 
the  most  extensive  and  aggravated  wounds  of  this  character,  under  very 
unpromising  circumstances,  are  on  record,  so  that  no  case  of  the  kind 
should  be  despaired  of.  The  following  recent  cases  may  be  quoted  in 
illustration  of  the  truth  of  this  statement : 


1  British  Medical  Journal,  Dec.  10,  1881,  p.  925. 
23 


354  THE    TREATMENT    OF    WOUNDS. 

1.  Case  reported  by  Simpson,1  of  Michigan.     Male,  30  years  of  age, 
cut  his  abdomen  open  with  a  razor,  while  in  the  woods.     Seen  by  the  sur- 
geon four  hours  after  the  occurrence.     Was  then  covered  by  an  old  bed- 
quilt,  which  was  adherent  to  the  protruding  intestines.     Wound  was  in 
middle  line,  eight  inches  in  length,  extending  from  the  ensiform  cartilage 
to  a  point  below  the  umbilicus.     Through  this  a  mass  of  intestines,  con- 
sisting of  eight  inches  of  transverse  colon  and  twelve  feet  of  small  intes- 
tine and  omentum  protruded  ;  the  intestines  were  dry  and  wrinkled,  cov- 
ered with  cinders,  dust,  sand,  and  a  variety  of  foreign  matter  which  had 
been  rubbed  in  as  the  man  had  rolled  over  and  over  on  the  ground  in  his 
agony.     Under  chloroform,  the  larger  bits  of  foreign  matter  were  picked 
off,  and  the  intestines  washed  in  water  from  a  neighboring  brook,  and 
the  protruding  viscera  returned.     A  quantity  of  blood  effused  into  the 
peritoneal  cavity  was  mopped  out  with  a  handkerchief.     The  wound  was 
closed  by  a  continuous  suture  applied  so  as  to  include  the  whole  thickness 
of  the  wound-edges.     Difficulty  was  experienced  in  preventing  the  omen- 
turn  from  protruding  while  the  suture  was  being  applied,  and  in  the  lower 
half  of  the  wound  it  became  adherent  to  and  united  with  the  lips  of  the 
wound.     The  man  was  then  removed  in  a  lumber  wagon  four  miles  to  a 
town,  and  placed  on  a  dirty  cot  bed  in  the  city  fire-engine  house.     Rapid 
recovery  without  an  untoward  symptom  took  place,  so  that  he  was  dis- 
charged from  treatment  on  the  fifteenth  day  after  the  occurrence. 

2.  The  second  case  2  is  very  similar  to  the  first.     A  male,  55  years  of 
age,  attempted  suicide,  and  cut  into  his  abdomen  with  a  large  knife  four 
successive  times.     When  first  seen,  three  hours  after  the  accident,  the  pa- 
tient was  found  lying  on  the  dirty  floor  of  a  cattle-hut,  in  a  fainting  state, 
with  all  the  small  intestines  and  the  whole  omentum  majus  protruding 
out  of  a  clean-cut  wound  which  extended  from  the  scrobiculus  cordis  far 
below  the  umbilicus.     There  were  seen  also  three  other  smaller  wounds, 
ah1  of  them  perforating  the  abdominal  wall.     The  protruded  parts,  which 
were  covered  with  mud  and  blood,  were  washed  with  tepid  water  and  re- 
turned, and  then  all  the  wounds  closed  with  silk  sutures,  and  dressed  with 
cold  water.     Three  weeks  later  the  patient  left  the  hospital,  having  recov- 
ered without  any  complication  except  a  small  abscess  in  the  abdominal 
wall  near  the  largest  wound. 

Out  of  307  cases  of  penetrating  incised  wounds  of  the  abdominal  cav- 

1  Medical  Gazette,  New  York,  1882,  p.  225. 

*  Sarmatsky,  Vra.chebn.iya  Vaidomosti,  St.  Petersburg,  1882,  No.  16. 


PROTRUSION    OF   VISCERA.  355 

ity  reported  by  Albanese,1  of  Palermo,  in  only  6  instances  did  death  result 
from  simple  diffuse  peritonitis.  In  these  cases,  protruding  intestinal  loops 
were  always  carefully  washed  with  carbolated  water,  and  any  wounds  in 
the  intestines  sutured  before  the  protrusion  was  returned. 

In  general,  the  rule  of  treatment  in  this  class  of  cases  is  to  cleanse  and 
disinfect  the  protruding  viscus  as  carefully  as  possible,  and  return  it  into 
the  abdominal  cavity,  after  which  the  wound  should  be  treated  as  one 
without  protrusion.  Attention  must  be  directed,  however,  to  modifica- 
tions of  this  rule  demanded  in  certain  circumstances. 

Intestine. — So  large  an  amount  of  intestine  may  have  escaped  through 
the  wound  that  it  can  no  longer  be  passed  back  through  the  opening  by 
which  it  escaped.  In  such  a  case  the  wound  must  be  enlarged  until  the 
return  of  the  protruding  intestine  is  possible  ;  care  should  be  taken  to 
make  the  incisions  at  those  portions  of  the  wound  which  resist  distention 
and  act  as  agents  of  constriction.  The  return  of  the  intestine  should  be 
followed  by  insertion  of  the  finger  to  determine  with  certainty  that  the 
gut  has  been  replaced  in  its  proper  cavity,  and  not  crowded  between  the 
peritoneum  and  the  superficial  tissues. 

The  difficulty  in  reduction  may  depend  on  the  distention  of  the  bowel 
by  flatus.  If  so,  an  attempt  to  press  it  back  into  the  portion  of  intestine 
within  the  abdomen  should  be  made.  If  this  is  unsuccessful,  and  the  pro- 
trusion is  great,  with  excessive  distention,  the  bowel  should  be  punctured 
with  an  aspirating  needle  through  which  the  gas  may  escape. 

The  intestine  may  have  been  strangulated  by  the  constriction  of  the 
wound  through  which  it  has  been  forced.  If,  after  the  constriction  has 
been  relieved,  the  circulation  in  the  previously  strangulated  loops  resumes 
its  natural  course,  reduction  of  the  gut,  and  closure  of  the  wound  should 
be  made.  If  gangrene11  is  already  present,  or  if  the  feeble  and  imperfect 
return  of  the  circulation,  after  dividing  the  stricture,  indicate  that  it  is 
inevitable,  the  bowel  should  be  left  in  the  wound,  to  the  margins  of  which 
it  will  have  contracted  adhesions,  an  incision  should  be  made  into  the 
bowel  and  an  artificial  anus  created. 

Omentum. — Protruding  omentum,  which  cannot  be  readily  replaced, 
should  be  ligated  at  its  base  and  cut  off ;  if  an  aseptic  ligature  has  been 
employed,  the  stump  may  be  dropped  back  into  the  abdomen,  and  the 
abdominal  wound  may  be  closed  ;  if  an  ordinary  ligature  be  used,  the 


1  Transactions  of  the  International  Medical  Congress,  London,  1881,  ii.,  437. 


356  THE   TREATMENT    OF    WOUNDS. 

omentum  must  be  left  in  the  wound,  and  healing  by  granulation  awaited. 
Protruding  omentum  that  is  very  dirty,  that  is  congested  in  any  degree, 
or  into  whose  substance  extravasations  of  blood  have  taken  place,  should 
be  excised.  If  the  size  of  the  omental  mass,  that  is  to  be  excised,  be  con- 
siderable, a  double  thread  should  be  passed  through  its  base,  and  each 
half  tied  separately. 

Protrusion  of  other  Viscera. — Protrusions  of  the  stomach  are  to  be 
treated  in  accordance  with  the  rules  for  the  intestines. 

In  cases  of  protrusion  of  the  bladder,  evacuation  of  the  urine  should 
first  be  secured  by  the  introduction  of  a  catheter,  after  which  its  reposi- 
tion may  be  effected  without  difficulty. 

Protrusions  of  portions  of  the  spleen,  or  of  the  liver  have  occurred. 
The  general  treatment  of  such  protrusion  should  be  the  same  as  that 
given  for  protruding  omentum. 

Two  cases  of  complete  protrusion  of  a  kidney  through  a  wound  have 
recently  been  recorded.1  In  both  cases  a  ligature  was  thrown  around  the 
pedicle  formed  by  the  vessels  and  ureter,  and  the  kidney  removed,  Re- 
covery ensued. 

PENETRATING  WOUNDS   OF   THE   ABDOMINAL   WALL   WITH   INJURY   OF 

VISCERA. 

In  the  treatment  of  this  class  of  wounds,  the  surgeon  will  need  to 
specially  consider  the  subjects  of  exploration  of  the  abdominal  cavity, 
arrest  of  intraperitoneal  haemorrhage,  suture  of  visceral  wounds,  primary 
cleansing  of  the  peritoneal  cavity,  secondary  cleansing  or  drainage,  and 
secondary  inflammatory  and  septic  complications. 

EXPLOKATION  OF  THE  ABDOMINAL  CAVITY. — The  evidences  that  an  abdom- 
inal viscus  has  been  wounded  may  be  either  positive  or  presumptive.  The 
escape  through  the  opening  in  the  parietes  of  the  contents  of  the  aliment- 
ary tube,  of  the  bile  or  of  the  urine,  or  the  protrusion  externally  of  the 
wounded  viscus,  so  that  the  wound  is  subject  to  actual  inspection,  alone 
can  be  considered  as  positive  proof  of  visceral  injury.  When  any  of  these 
conditions  are  present,  the  duty  of  the  surgeon  is,  clearly,  to  enlarge  the 
opening  in  the  abdominal  wall,  or  to  make  a  new  one  in  a  more  favorable 
location,  sufficiently  to  admit  of  examination  of  the  viscera  in  the  track  of 

'Brandt:  Wiener  Med.  Wochentclirift,  1873.  Marvand  :  Recueil  de  Mem.  de  Ned. 
de  Chintrg.,  etc.,  1875,  xxxi.,  502. 


WOUNDS    OF    ABDOMINAL    VISCERA.  357 

the  wound,  to  detect  and  ligate  bleeding  vessels,  to  suture  intestinal  rents, 
and  to  thoroughly  cleanse  the  peritoneal  cavity  of  extravasated  matters. 

In  the  great  majority  of  cases  of  visceral  wound,  however,  positive 
evidence  is  wanting,  and  simply  a  more  or  less  strong  presumption  of  the 
fact  of  the  wound  exists.  In  these  cases  it  should  first  be  established,  by 
superficial  exploration,  that  penetration  of  the  peritoneal  cavity  has  taken 
place.  In  this  respect  an  exception  should  be  made  to  the  general  rule 
given  in  the  case  of  gunshot  wounds  to  abstain  from  all  primary  explora- 
tion of  their  track.  Gunshot  wounds  of  the  abdominal  walls  should  be 
explored  in  all  cases,  as  soon  as  the  necessary  requisites  of  aseptic  cleanli- 
ness can  be  complied  with,  sufficiently  to  determine  whether  they  do  or  do 
not  penetrate  the  peritoneal  cavity. 

The  fact  of  penetration  having  been  established,  the  further  course  to 
be  pursued  becomes  a  matter  of  grave  consideration,  whenever  signs  of  al- 
ready impending  dissolution  do  not  absolve  the  surgeon  from  all  responsi- 
bility. With  but  few  exceptions,  this  class  of  wounds  are  gunshot  wounds. 
A  policy  of  non-interference,  and  of  expectant  treatment  by  rest,  cold,  and 
opiates  has  been  pursued  in  the  past  in  the  treatment  of  the  cases  under 
discussion.  Notwithstanding  this  treatment,  87.72  per  cent,  of  all  pene- 
trating gunshot  wounds  of  the  abdomen,  during  the  war  of  the  Rebellion, 
terminated  in  death.  During  the  Crimean  war,  91.7  per  cent,  of  the  cases 
among  the  French,  and  92.5  per  cent,  among  the  English,  died.  Of  the 
cases  that  recover,  the  larger  proportion  are  among  those  in  which  the 
protrusion  of  the  viscera,  or  the  adhesion  of  the  margins  of  the  internal 
visceral  wound  to  the  margins  of  the  external  wound  so  that  the  contents 
of  the  viscus  escape  externally,  relieve  the  surgeon  from  all  doubt  as  to  the 
course  he  should  pursue.  Of  the  few  cases  that  remain,  in  some  the  re- 
covery has  taken  place  though  positive  evidence  of  visceral  penetration  has 
been  given  by  the  subsequent  voiding  of  the  bullet  per  anum,  and  in  yet 
others  in  which  the  symptoms  have  afforded  strong  presumptive  evidence 
•of  visceral  wound,  as  in  the  following  case,  reported  by  Schapps : '  a  male, 
aged  twenty  years,  was  admitted  into  St.  Vincent's  Hospital,  New  York,  in 
the  service  of  Dr.  Chas.  Phelps,  May  26,  1880,  having  been  shot  by  a  pis- 
tol at  a  distance  of  three  feet.  The  bullet  penetrated  the  abdominal  wall 
two  and  a  half  inches  above  and  to  the  left  of  the  umbilicus.  General  con- 
dition when  admitted  fair,  but  within  half  an  hour  experienced  great  de- 


1  Annals  of  Anatomy  and  Surjery,  1881,  iv. ,  p.  88. 


358  THE    TREATMENT    OF    WOUNDS. 

pression  of  vital  powers,  and  vomited  considerable  blood.  Ice,  stimulants, 
and  opium  were  given.  He  was  discharged  on  the  twenty-second  day 
thereafter,  cured. 

It  should  also  be  remarked  that  instances  have  been  recorded  in  which 
the  abdominal  cavity  has  been  traversed  by  a  bullet,  or  transfixed  by  a 
weapon,  without  injury  to  any  of  its  viscera. 

In  any  individual  case,  the  possibility  that  it  may  prove  to  be  one  of 
the  rare  exceptions  to  the  general  rule  of  fatality,  will  have  its  influence  on 
the  decision  of  the  surgeon  as  to  the  course  which  he  shall  pursue. 

The  cause  of  death  in  the  fatal  cases  is  either  shock,  haemorrhage,  sep- 
ticaemia, or  septic  peritonitis.  Death  from  the  first  two  causes  is  speedy, 
so  that,  except  in  rare  instances  of  slowly  accumulating  blood-extravasa- 
tions, they  do  not  require  special  consideration  here.  The  two  latter  causes 
of  death,  septicaemia  and  septic  peritonitis,  are  more  slow  in  their  opera- 
tion, and  hence  engage  the  more  particular  solicitude  of  the  surgeon  in 
the  treatment  that  he  may  give.  Most  important  of  all  would  be  their 
prevention,  but  in  these  injuries  the  cause  is  inherent  in  the  wound  itself, 
from  the  extravasation  of  the  septic  contents  of  the  wounded  organs  into 
the  peritoneal  cavity.  Free  incision,  exploration,  disinfection,  and  drainage 
constitute  the  treatment  for  similar  conditions  in  other  regions  of  the  body 
and  would  be  resorted  to  in  all  cases  of  penetrating  wounds  of  the  abdomi- 
nal cavity  were  it  not  for  the  special  dangers  which  such  practice  involves. 
These  are  the  shock  of  the  incision  and  the  handling  of  the  abdominal 
contents,  the  danger  of  awakening  fatal  inflammation  by  the  operation 
itself,  the  possibility  of  disturbing  repair  which  if  left  alone  would  have 
accomplished  recovery,  and  finally,  the  possibility  of  overlooking  wounds 
from  which  subsequent  extravasations  would  occur. 

In  forming  his  final  conclusion  as  to  the  course  which  he  should  pursue 
in  the  treatment  of  those  cases  in  which  presumptive  evidence  only  exists 
as  to  the  occurrence  of  visceral  injury,  these  dangers  attending  the  pro- 
cedure of  incision  of  the  abdominal  wall,  exploration  and  cleansing  of  its 
cavity,  are  the  only  conditions  that  can  weigh  for  much.  They  have  been 
sufficient,  heretofore,  to  deter  from  its  practice.  The  great  proportion  of 
recoveries,  however,  which  have  followed  the  free  abdominal  incisions,  and 
the  prolonged  manipulations,  and  the  often  great  traumatism,  inflicted 
upon  the  abdominal  viscera,  in  the  operation  of  ovariotomy,  as  performed 
by  many  surgeons,  has  demonstrated  that  less  danger  attends  mere  trau- 
matic injuries  of  the  peritoneum  than  had  been  supposed  ;  the  dangers  of 


EXPLORATION    OF    PERITONEAL    CAVITY.  359 

septic  infection  have  also  been  more  clearly  defined  by  the  experience  of 
ovaiiotomists.  In  view  of  the  more  accurate  knowledge  now  possessed  as 
to  the  management  of  peritoneal  wounds,  encouragement  is  given  to  a 
more  ready  and  frequent  resort  to  immediate  ventral  incision  for  purposes 
'  of  exploration  and  cleansing  in  cases  where  the  symptoms  establish  a 
strong  presumption  of  visceral  injury.  The  danger  that  by  such  proced- 
ure adhesions  would  be  broken  up,  which  if  let  alone  would  have  accom- 
plished spontaneous  recovery,  is  too  infinitesimal  to  be  permitted  to  have 
any  weight ;  while  the  final  danger  that  possibly  some  wound  might  fail  to 
be  detected  and  secured,  as  the  result  of  which  all  that  had  been  done 
would  be  useless,  should  stimulate  rather  to  increased  thoroughness  in  the 
exploration  than  to  refusal  to  attempt  it  at  all  In  this  connection  the 
following  language  of  J.  Marion  Sims  '  may  be  quoted  : — 

"  I  have  the  deepest  conviction  that  there  is  no  more  danger  of  a  man's 
dying  of  a  gunshot  or  other  wound  of  the  peritoneal  cavity,  properly 
treated,  than  there  is  of  a  woman's  dying  of  an  ovariotomy,  properly  per- 
formed. Ovarian  tumors  were  invariably  fatal,  till  McDowell  demonstrated 
the  manner  of  cure,  which  has  now  reached  such  perfection  that  we  cure 
from  90  to  97  per  cent,  of  all  cases.  And  by  the  application  of  the  same 
principles  that  guide  us  in  ovariotomy  to  the  treatment  of  shot  wounds 
penetrating  the  abdominal  cavity,  there  is  every  certainty  of  attaining  the 
same  success  in  these  that  we  now  boast  of  in  ovariotomy." 

In  any  exploration  of  the  peritoneal  cavity,  the  surgeon  must  observe 
every  precaution  lest  he  himself,  in  his  manipulations,  introduce  septic 
matter.  Every  precaution  of  asepsis  should  be  rigidly  obsei'ved  in  the 
persons  of  the  surgeon  and  of  his  assistants,  and  in  his  sponges,  instru- 
ments, and  appliances.  The  external  surface  of  the  abdomen  must  be 
carefully  cleansed  and  disinfected,  and  the  subsequent  dressings  should  be 
antiseptic  in  character. 

ARREST  OF  INTRAPERITONEAL  HAEMORRHAGE. — "Whenever  evidences  of  intra- 
peritoneal  haemorrhage  are  present,  there  is  but  one  resource,  the  en- 
largement of  the  external  wound,  or  the  making  of  an  incision  through 
the  abdominal  wall  in  a  more  suitable  situation,  and  the  exposure  and 
ligation  of  the  bleeding  vessel.  Aseptic  silk  or  catgut  should  be  used  ; 
the  ligature  should  be  cut  short  and  left  in  the  peritoneal  cavity. 

Parenchymatous  haemorrhage  from  the  tissue  of  a  wounded  liver, 
spleen  or  kidney  should  be  arrested  by  the  actual  cautery. 

1  British  Medical  Journal,  March  4,  1882. 


360 


THE   TREATMENT    OF    WOUNDS. 


SUTURE  OF  VISCERAL  WOUNDS. — In  suturing  intraperitoneal  wounds  of 
the  alimentary  canal  or  of  the  urinary  or  gall  bladders,  the  apposition  of 
the  serous  surfaces  adjacent  to  the  wound  edges,  rather  than  of  the  wound 
edges  themselves,  is  of  the  greatest  importance.  An  effectual  method  of 
accomplishing  this  in  ordinary  wounds  is  the  method  of  Lembert, '  known 
as  "  Lembert's  suture  "  (Figs.  106  and  107). 


FIG.  106.  FIG.  107. 

FIG.  106.— Lembert's  Suture.     A,  exterior  view  of  suture,  in  place  ;   B,  transverse  section  ;   C,  interior 

view,  showing  incurving  of  the  serous  coat. 
FIG.  107. — Lembert's  Suture  as  Applied  to  a  Transverse  Wound  ;  Exterior  View. 

The  suture  is  applied  as  follows  :  at  a  point  about  one-third  of  an  inch 
from  the  edge  of  the  wound  the  peritoneal  coat  is  pierced  from  without 
inwards  (Fig.  107,  a),  the  needle  is  then  caused  to  glide  between  the  serous 
and  mucous  coat  for  one-half  the  distance  between  the  point  of  entrance 
and  the  wound-margin,  it  is  then  brought  out  through  the  serous  coat 
again  (Fig.  107,  6),  carried  across  the  wound,  and  entered  on  the  other 
side  (Fig.  107,  c),  at  a  similar  distance  from  the  wound  margin  and  the 
same  manoeuvre  repeated  in  reverse  order.  When  the  loops  are  tied,  the 
tension  causes  the  edges  to  be  inverted  as  a  natural  consequence,  and  the 
serous  surfaces  are  held  in  secure  apposition.  The  stitches  should  be  in- 


1  Lembert :  Sur  V  enterorTiaphie.     Repertoire  d'anat.,  dephysiol.  pathol.,  1827. 


LEMBERT'S  SUTURE.  361 

troduced  quite  closely  together,  at  intervals  not  exceeding  a  quarter  of  an 
inch,  in  order  that,  should  distention  of  the  bowel  by  gas  occur  before 
firm  adhesion  of  the  bowel  has  taken  place,  no  gaping  even  then  should 
be  possible.  The  threads  should  not  be  drawn  so  tightly  as  to  constrict 
the  tissues,  and  cut  them  through,  but  simply  firmly  enough  to  keep  the 
parts  in  apposition.  The  threads  become  imbedded  in  the  plastic  exudate 
that  forms  the  new  bond  of  union,  and  give  no  further  trouble. 

The  choice  of  a  material  for  the  suture,  providing  it  is  aseptic,  may  be 
either  silk  or  catgut.  Surgeons  differ  in  the  preference  to  be  given  to 
these  materials.  Czerny,  Billroth,  Madelung,  Baum,  Bouilly,  and  others, 
consider  silk  as  the  best.  Dittel,  Schede,  Julliard,  Rydigier,  and  others 
prefer  catgut. '  The  speedy  softening  of  catgut  has  been  charged  with  ex- 
posing wounds  in  which  it  was  employed  to  the  danger  of  being  left  with- 
out support  too  early,  but  without  sufficient  reason,  if  it  has  been  fastened 
in  the  first  place  with  care,  for  so  rapidly  does  the  adhesion  of  the  serous 
surfaces  take  place,  that  no  danger  is  to  be  feared  from  the  softening  of 
the  catgut.  The  disasters  which  have  taken  place  have  been  due  either 
to  lack  of  care  in  the  knotting  of  the  suture,  or  to  sloughing  of  the  in- 
testinal wall.  Those  who  advocate  the  use  of  silk  find  their  chief  reasons 
for  the  preference  in  the  fact  that  its  application  is  more  easy,  and  a 
finer  needle  may  be  employed  with  it,  points  which,  mough  apparently 
trivial,  are  of  much  practical  importance. 

Ordinary  round  sewing  needles,  neither  flattened  nor  with  cutting 
edges,  should  be  used  for  introducing  the  suture,  in  order  that  the  wound 
made  by  the  needle  may  be  as  small  as  possible,  and  free  from  haemor- 
rhage. 

During  the  application  of  the  suture,  it  would  be  best  that,  if  possi- 
ble, the  wounded  part  be  drawn  out  of  the  abdomen,  and  the  wound  in 
the  parietes  of  the  abdomen  kept  closed  as  much  as  possible  by  the  hands 
of  an  assistant,  or  better,  by  a  sufficient  number  of  temporary  deep 
sutures  to  lessen  the  amount  of  exposure  of  the  abdominal  contents. 

Modifications  of  the  suture  of  Lembert  have  been  proposed  by  Jobert, 
Emmert,  Grely,  Gussenbauer,  and  Czerny. 

Jobert  carried  his  needle  through  the  mucous,  as  well  as  the  serous 
coat  of  the  viscus,  puncturing  the  inverted  edges  of  the  wound  in  their 
whole  thickness  (Fig.  108,  A,  B,  C). 

1  Bouilly  and  Assaky :  De  la  resection  circulaire  et  de  la  suture  de  rintestin,  etc. 
Revue  de  Chirurgie,  1883,  p.  383. 


362 


THE   TREATMENT    OF    WOUNDS. 


When  an  irritating  thread  must  be  used,  and  it  is  wished  that  the 
suture  may  cut  through  and  ultimately  fall  into  the  lumen  of  the  viscus, 
this  method  is  to  be  adopted,  and  the  sutures  should  be  drawn  very 
tightly. 

Emmert's  suture  was  devised  to  overcome  a  presumed  objection  to  the 
suture  of  Lembert  that  it  did  not  have  sufficient  hold  upon  the  tissues, 
and  that  the  cicatrix  projected  too  much  into  the  interior  of  the  viscus. 

The  method  of  its  application  is  shown  in  Fig.  109.  The  threads  are 
carried  through  the  whole  thickness  of  the  visceral  wall.  A  series  of  in- 


FIG.  1C8.— Jobert's  Suture. 

terrupted  stitches  result  by  tying  together  the  opposite  threads,  a,  a  and 
d,  d.  It  is  more  intricate  and  tedious  of  application  than  the  suture  of 
Lembert  or  of  Jobert,  while  these  have  been  found  to  be  sufficiently  secure. 
The  suture  of  Gely  (Fig.  110)  is  executed  with  a  long  thread,  each  ex- 
tremity of  which  is  armed  with  a  needle.  The  whole  thickness  of  the  wall 
of  the  viscus  is  pierced  about  one-third  of  an  inch  from  the  wound-mar- 
gin, at  one  end  of  the  wound  (Fig.  110,  a)  from  without  inward,  the 
thread  is  then  carried  laterally  and  parallel  with  the  edge  of  the  wound 
for  about  one-third  of  an  inch,  and  then  brought  out  again  the  same  dis- 
tance from  the  wound  margin  as  before  (Fig.  110,  b).  This  procedure  is 
repeated  with  the  second  needle  on  the  opposite  edge,  at  "c"  and  "d ;'* 
this  done,  the  threads  are  crossed  over  the  gaping  wound ;  the  needle 


INTESTINAL    SUTURES. 


363 


which  found  an  exit  at  "  b  "  is  now  introduced  at  the  point  "  d  "  of  the  op- 
posite side,  and  vice  versa  with  the  other  needle.  Thus  the  surgeon  con- 
tinues, till  the  entire  wound  is  closed  by  the  suture.  The  extremities 
having  been  drawn  tight,  the  knot  is  tied  and  cut  short.  The  result  is 
excellent,  but  the  same  criticism  is  applicable  to  this  as  to  the  suture  of 
Emmert. 

Czerny's  suture.  If,  in  addition  to  the  ordinary  Lembert  suture,  the 
cut  edges  of  the  peritoneal  coat  be  first  sutured  together  by  a  row  of  fine 
sutures,  one  of  which  is  seen  already  placed  in  Fig.  107,  and  then  the  in- 


Fio.  109. — Emmert's  Suture. 


Fio.  110.— G61y's  Suture. 


vagination  and  suture  of  the  more  distant  portion  of  the  serous  coat  be 
done  as  usual,  the  sealing  up  of  the  wound  will  be  doubly  insured.  This 
is  the  suture  of  Czerny. 

Fig.  Ill  gives  a  diagrammatic  representation  of  a  transverse  section  of 
a  bowel  to  which  this  suture  has  been  applied. 

Gussenbauer's  suture  is  essentially  the  same,  differing  only  in  that 
both  the  internal  and  external  stitches  are  made  with  the  same  thread,  the 
in  and  out  course  which  the  thread  is  made  to  take,  causing  a  figure  of  8 
to  be  described  by  it,  are  seen  in  the  diagram,  Fig.  112. 

More  simple,  and  m<ye  quickly  and  easily  executed  than  any  of  the 
methods  which  have  been  described,  and  in  all  ordinary  longitudinal 
wounds  of  the  intestine  or  bladder,  sufficiently  secure  and  reliable,  is  the 
ordinary  continuous  suture  (Fig.  113),  applied  with  an  over  and  over 


364 


THE    TREATMENT    OF    WOUNDS. 


stitch,  care  being  taken  to  tuck  in  the  edges  so  as  to  invert  the  serous 
edges,  and  bring  a  line  of  serous  membrane  into  apposition  as  the  thread 
is  drawn  tight.  In  many  of  the  accidental  wounds  which  may  demand 


M  UCOSA. 

Musc.w., 
SEROSA. 


Fio.  111. — Czerny's   Intestinal  Suture. 


PlQ.  112. — Gussenbauer's  Intestinal  Suture. 


the  application  of  an  intestinal  suture,  the  conditions  may  be  such  as  to 
make  the  more  complicated  sutures  difficult,  if  not  impossible,  of  practice. 
In  such  cases  the  continuous  suture  may  be  used  with  every  confidence  of  a 
good  result.  Nussbaum '  expresses  a  decided 
preference  for  the  simple  continuous  suture,  as- 
serting that  it  is  applicable  in  transverse,  as  well 
as  in  longitudinal  wounds,  and  that,  even  where  a 
complete  solution  of  continuity  of  the  intestinal 
tube  exists,  it  answers  all  demands,  being  easily 
executed,  and  in  its  results  not  inferior  to  any  of 
the  other  methods. 

The  suturing  together  of  the  divided  portions 
of  an  intestine,  when  complete  division  of  the  tube 
has  occurred,  requires  further  consideration.  If, 
in  a  given  case,  which  is  the  upper  and  which 
the  lower  portion  of  the  tube  can  be  positively 
settled,  Nussbaum  advises  that  the  end  of  the 
upper  tube  be  invaginated  into  that  of  the  lower, 
whose  edge  is  first  turned  in  so  that  serous  sur- 
face shall  be  apposed  to  serous  surface,  and  the 

FIG.  us.— The  continuous  in-  two  be  secured  after  the  method  of  Jobert.     Fig. 
114,  A,  B,  shows  the  re^tion  of  the  two  ends  to 

each    other  when    invaginated.      The  steps  of   the  procedure   are   thus 
described  by  Nussbaum  : — First,  the  two  divided  extremities,   "  x "  the 

1  Die  Verletzungen  des  Unterleibes.     Deutsche  Chirurgie,  Lief.  44,  p.  1£9. 


THE   INVAGINATION    SUTURE. 


365 


upper  portion,  and  "y"  the  lower  portion,  are  dissected  up  from  the 
mesentery ;  secondly,  the  upper  portion,  "x,"  is  invaginated  by  means 
of  two  sutures  into  the  lower  tube,  "y"  (see  Fig.  115).  The  upper  tube 
is  supplied  with  sutures,  affixed  to  opposite  sides  (Fig.  115,  a  a),  about 
two-thirds  of  an  inch  from  the  edge  of  the  wound.  Each  extremity  of  the 
suture  is  armed  with  a  needle,  each  of  which  are  then  made  to  pierce  the 
doubled-in  lower  portion,  "y"  (Fig.  115,  b,  c,  and  d,  e,  the  punctures  6 
and  c,  and  d  and  e,  being  situated  from  one-third  to  one-half  an  inch 
from  each  other).  The  next  step  is  the  tying  of  the  sutures,  b  and  c, 
whereby  the  intestine  "x"  is  drawn  into  the  lumen  of  the  tube  "y."  At 


FIG.  114. — Jobert's  Method  of  Invagination. 


the  points  d  and  e,  the  procedure  is  repeated.  The  tension  should  be 
moderate,  otherwise  the  nutrition  of  the  surrounding  tissues  will  be  dis- 
turbed, and  gangrene  result.  The  operation  is  completed  by  the  intro- 
duction of  the  necessary  number  of  sutures  to  keep  the  ends  of  the  bowel 
in  position  and  prevent  extravasation.  The  continuous,  or  some  form  of 
the  interrupted  suture  may  be  used.  Bouilly  and  Assaky  (op.  citat.)  reject 
the  method  by  invagination,  as  long,  difficult  of  execution,  and  liable  to 
be  followed  by  symptoms  of  internal  obstruction,  and  express  their  belief 
that  the  suture  of  Lembert  is  sufficient  in  every  case,  provided  the  threads 
are  sufficiently  near  together.  From  them  may  be  quoted  the  following 
practical  directions  in  performing  the  operation  : 

One  or  two  points  of  suture  should  be  first  applied  upon  the  lips  of  the 
triangular  wound  in  the  mesentery,  two  suffice  usually  to  approximate  these 
parts  up  to  the  concave  border  of  the  intestine.  It  is  "well  to  place  a  point 


366 


THE    TREATMENT    OF    WOUNDS. 


of  suture  at  the  place  where  the  mesentery  is  to  be  attached  to  the  intes- 
tine and  to  secure  it  to  the  intestinal  wall.  The  first  point  of  intestinal 
suture,  the  highest,  is  placed  quite  near  the  new  meseuteric  insertion  ; 
immediately  afterward  the  second  thread  is  placed  at  a  point  diametri- 
cally opposite,  that  is,  on  the  convex  border  of  the  intestine.  These  two 
threads,  in  position  and  knotted,  hold  the  intestinal  ends  well  in  the  posi- 
tions which  they  should  occupy  and  facilitate  much  the  introduction  of  the 
other  threads  ;  these  are  successively  introduced,  working  from  the  con- 
cave border  to  the  convex.  To  reach  the  posterior  surface,  it  is  necessary 
to  raise  up  the  loop  already  sutured.  The  introduction  of  the  posterior 


FIG.  115.— The  Invagination  Suture. 


FIG.  116.— The  Invagination  Completed. 


series  of  threads  is  particularly  difficult  near  the  insertion  of  the  mesentery, 
where,  indeed,  special  care  should  be  exercised.  Each  thread  should  be 
tied  as  it  is  put  in  place.  The  number  of  points  of  suture  should  be  con- 
siderable. The  threads  should  be  very  near  together,  for  points  separated 
by  an  interval  of  one  or  two  lines,  where  the  intestine  is  collapsed,  would 
be  found  to  be  distant  from  each  other  a  quarter  of  an  inch  and  more 
when  that  state  of  tympanitis  occurs,  which  always  follows,  though  per- 
haps only  temporarily,  every  intraperitoneal  operation.  The  needle  should 
not  pierce  the  intestinal  tissues  more  than  a  third  of  an  inch  away  from 


CLEANSING    THE    PERITONEAL    CAVITY.  367 

H 

the  cut  margin.  Should  a  decided  difference  in  the  calibre  of  the  two 
ends  exist,  the  larger  might  be  retrenched  by  the  removal  of  a  longitudinal 
gore  from  its  wall  and  then  the  apposition  and  suture  of  the  two  ends  be 
effected,  or  the  union  of  the  two  might  be  accomplished  as  far  as  possible, 
and  then  the  gaping  portion  left  be  secured  in  the  external  wound  and  a 
temporary  artificial  anus  formed. 

PRIMARY  CLEANSING  OF  THE  PERITONEAL  CAVITY. — In  all  wounds  attended 
with  extravasation  into  the  peritoneal  cavity  of  matter,  either  septic  or 
prone  to  become  septic,  the  most  thorough  and  scrupulous  cleansing  of 
the  cavity  must  be  practised.  The  external  wound  must  be  enlarged,  if 
necessary,  sufficiently  to  admit  of  the  complete  performance  of  this  duty. 
After  all  haemorrhage  has  been  absolutely  and  definitely  arrested,  and 
suture  of  the  visceral  wounds  has  been  accomplished,  all  foreign  matter, 
blood  and  serum  must  be  removed.  For  this  purpose  irrigations  and 
spongings  may  be  used.  The  irrigating  fluid  s,hould  be  blood-warm,  and 
should  be  made  to  approximate  the  specific  gravity  of  the  serum  of  the 
blood,  by  the  solution  in  it  of  a  small  quantity  of  common  salt.  The  noz- 
zle of  the  irrigating  tube  should  be  introduced  deeply  into  the  peritoneal 
recesses  both  of  the  abdomen  and  of  the  pelvis.  While  the  irrigation  is 
being  practised,  the  position  of  the  patient  can  be  changed  so  as  to  facil- 
itate the  free  escape  of  the  irrigating  fluid.  Sponging  should  be  done  by 
soft  and  pure  sponges,  secured  to  a  sponge-holder  or  grasped -in  a  forceps, 
by  which  they  are  carried  down  to  the  farthest  recesses  of  the  peritoneum. 
No  loose  sponge  should  be  thrust  into  the  abdominal  cavity,  on  account  of 
the  danger  of  its  being  overlaid  by  the  intestinal  folds  and  left  in  the 
cavity.  The  sponging  should  be  continued  until  the  peritoneum  is  clean 
and  dry.  In  the  absence  of  the  desired  purified  sponges,  sponging  must 
not  be  dispensed  with,  removal  of  intra-peritoneal  effusions  must  in  all 
cases  be  made  as  perfectly  as  possible,  with  the  best  means  at  the  com- 
mand of  the  surgeon. 

DRAINAGE. — The  conditions  which  the  peritoneal  cavity  presents  are 
such  as  to  alter  the  relations  of  artificial  drainage  in  the  case  of  wounds 
within  it.  As  has  been  pointed  out  by  Mr.  Lister, '  the  large  size  of  the 
cavity  prevents  the  occurrence  of  tension  within  it,  though  copious  secre- 
tion may  take  place.  The  absorptive  powers  of  the  serous  lining  suffice, 
in  many  cases,  to  rapidly  remove  effusions,  and  thus  to  prevent  their 
accumulation  and  putrefaction.  The  natural  great  vital  resisting  power 

1  Transactions  International  Medical  Congress,  1881,  vol.  ii.,  p.  370. 


368  THE   TREATMENT    OF    WOUNDS 

of  the  peritoneum  enables  it  to  control  and  overcome  septic  influences  to 
a  certain  degree.  On  the  other  hand,  special  disadvantages  attend  the 
use  of  artificial  drains  in  wounds  of  the  abdominal  cavity.  They  have 
been  summarized  by  Knowsley  Thornton  '  as  follows  : 

1.  Dangers  of  admitting  infective  material  through  the  tube. 

2.  Danger  from  the  removal  of  serum  and  blood  from  the  peritoneum 
in  an  exhausted  patient.     Aseptic  peritoneal  contents  are  reabsorbed  and 
feed  the  patient. 

3.  The  tube  causes  a  weak  spot  in  the  ventral  wall  for  subsequent 
hernia. 

4.  The  slow  healing  of  the  tube-opening  prolongs  convalescence,  and 
exposes  the  patient  to  the  additional  risks  of  an  open  wound. 

The  practical  conclusion  may  be  accepted  that  when  thorough  primary 
cleansing  of  the  cavity  has  been  done,  the  wound  may  be  closed  with 
every  expectation  of  future  freedom  from  septic  infection.  The  expression 
of  Spencer  Wells  "  is,  that  in  his  cases  of  abdominal  section,  since  he  has 
adopted  antiseptic  precautions,  either  intra-peritoneal  fluids  do  not  form, 
or,  if  they  do,  they  do  not  putrefy,  but  are  absorbed  without  doing  any 
harm.  The  rule  adopted  by  Keith,*  in  cases  of  ovariotomy,  is  to  use  a 
drainage-tube  whenever  a  constant  oozing  of  blood  continues  from  sur- 
faces exposed  by  the  tearing  away  of  adhesions,  so  as  to  prevent  the 
abdomen  from  being  dried  by  sponging.  His  language  is  :  "  Tie  every- 
thing ;  stop  the  bleeding  and  leave  the  abdomen  dry  ;  and  when  you  can't 
leave  it  dry,  put  in  a  drain.  Of  course  this  applies  to  bad  cases  only  ;  and 
you  will  not  get  bad  cases  well  without  draining."  The  following  practical 
observations,  by  the  same  surgeon,  as  to  the  manner  of  using  drainage- 
tubes,  may  be  quoted  in  addition  :  "I  put  the  drainage-tube  through  the 
abdominal  wall.  It  is  a  small,  straight  glass  tube,  adapted  to  the  depth  of 
the  pelvis.  You  must  see  that  it  does  not  press  injuriously  on  the  rectum. 
I  feel  how  it  is  lying  on  the  rectum,  and  if  it  is  making  pressure,  I  shift  it 
up  a  little  bit  I  cover  it  with  a  sponge,  and  wrap  that  in  an  India-rubber 
cloth  for  cleanliness.  Doing  this  way  you  may  often  drain  for  a  week  and 
not  a  drop  escape  on  the  dressing  or  the  dress,  it  being  all  collected  in  the 
sponge.  I  examine,  usually,  within  four  or  five  hours  to  see  if  anything  is 
on  the  sponge.  When  the  stuff  will  not  run  out  itself,  I  get  it  out  by 
putting  a  syringe  in  the  tube  and  sucking  it  out.  I  change  the  sponge 

1  Ibidem,  p.  235.  *  Ibidem,  p.  228. 

1  American  Practitioner,  November,  1881. 


WOUNDS    OF   THE    PELVIS.  369 

night  and  morning.  I  formerly  kept  the  drainage-tube  in  six  days  or  a 
week,  till  the  serum  got  quite  sweet  and  pure  ;  but  now  I  take  it  out  gen- 
erally within  forty-eight  hours.  If  the  amount  comes  down  to  a  drachm 
or  two,  I  don't  mind  taking  the  tube  out,  and  that  without  any  kind  of 
precautions.  After  all,  though,  you  must  be  governed  by  the  quantity 
that  comes." 

The  application  of  the  fruits  of  the  experience  of  ovariotomy  wounds 
to  the  treatment  of  accidental  penetrating  wounds  of  the  abdomen  is  di- 
rect and  immediate.  Whenever  from  the  nature  of  the  wound,  or  the  cir- 
cumstances attending  it,  all  fluids  likely  to  become  septic  are  not  removed 
in  the  primary  cleansing  of  the  peritoneal  cavity,  their  subsequent  escape 
by  drainage  must  be  provided  for.  The  drainage-tube  may  be  inserted 
either  through  the  original  accidental  wound,  or  through  one  made  by  the 
surgeon,  as  the  conditions  of  the  special  case  may  dictate. 

PERITONITIS  AND  SEPTICAEMIA. — The  so-called  traumatic  peritonitis  is  in 
all  cases  a  septic  inflammation,  and  kills  quickly  by  the  rapid  absorption 
of  the  abundant  septic  products — ptomiiines — which  are  drank  up  quickly 
by  the  serous  membrane  as  they  are  generated  in  the  copious  inflamma- 
tory secretions.  The  one  imperative  thing  to  be  accomplished  by  way  of 
treatment  is  to  secure  the  immediate  removal  of  the  poisonous  exudations. 
This  may  require  a  reopening  of  the  abdomen,  repetition  of  the  irrigations, 
and  more  effective  provisions  for  drainage.  The  presence  of  diffuse  peri- 
tonitis is  not  a  counter-indication  to  such  opening  and  cleansing,  but,  on 
the  other  hand,  is  a  condition  that  directly  calls  for  it. 

WOUNDS   OF   THE  PELVIS. 

The  wounds  of  the  pelvis  of  which  special  mention  must  be  made  arc- 
those  of  the  bladder,  and  those  involving  the  rectum  and  anus. 

WOUNDS  OF  THE  BLADDER. — The  wounds  of  this  organ  may  be  caused 
by  internal  rupture  without  external  wound ;  may  be  complicated  by.  ex- 
ternal wound;  may  be  inflicted  by  the  surgeon.  Special  indications  to  be 
fulfilled  in  their  treatment  centre  about  the  prevention  and  treatinejit  of 
the  disturbances  caused  by  the  extravasation  of  the  contents  of  the  organ. 
They  are :  (1)  To  remove,  as  soon  as  possible,  extravasated  urine.  (2)  To 
prevent  further  escape  of  urine  into  surrounding  connective-tissue  or  peri- 
toneal sac.  (3.)  To  meet  such  symptoms  of  shock,  peritoneal  inflamma- 
tion or  urinary  infiltration  as  may  appear.  The  course  to  be  pursued  in 


370  THE    TREATMENT    OF    WOUNDS. 

meeting  the  two  first  indications  will  vary  according  as  the  wound  is  extra- 
or  intra-peritoneal. 

In  extra-peritoneal  wounds,  the  removal  of  extravasated  urine  requires 
free  and  deep  incisions  into  the  infiltrated  tissues. 

In  intra-peritoneal  wounds,  the  conditions  are  identical  with  those  al- 
ready discussed  in  connection  with  wounds  of  the  hollow  viscera  of  the 
abdomen,  and  the  same  method  of  procedure  must  be  adopted,  free  exter- 
nal incision  of  the  abdominal  wall,  suture  of  the  rent  in  the  viscus,  and  most 
careful  cleansing  of  the  peritoneal  cavity  of  all  extravasated  matters.  The 
well-known  case  reported  by  Walter,1  of  Pittsburg,  illustrates  the  value  of 
laparotomy  and  cleansing  of  the  peritoneal  sac,  although  it  is  not  beyond 
criticism,  since  the  suture  of  the  vesical  wound  was  neglected,  happily, 
however,  without  evil  result  in  this  instance,  owing  to  the  location  of  the 
wound  in  the  fundus,  and  the  continuous  use  of  the  catheter.  In  this 
case  a  man  22  years  of  age,  had  received  a  blow  on  the  hypogastric  re- 
gion and  immediately  felt  a  sharp  pain  with  an  urgent  desire  to  urinate, 
which  he  could  not  accomplish.  After  some  hours,  the  belly  began  to 
swell,  the  pulse  became  small  and  frequent,  and, the  respiration  rapid.  A 
catheter  brought  away  a  minute  quantity  of  bloody  urine.  Ten  hours 
after  the  injury,  no  urine  passing  by  the  catheter,  the  abdomen  was 
opened  in  the  linea  alba  by  an  incision  beginning  one  inch  below  the  um- 
bilicus and  terminating  one  inch  above  the  pubes,  to  the  extent  of  six 
inches.  The  intestines  were  found  inflated,  their  peritoneal  coat,  as  well 
as  that  lining  the  interior  of  the  abdominal  walls,  already  showing  evident 
marks  of  congestion.  A  soft  sponge  was  then  cautiously  introduced  into  the 
abdomen,  with  which  the  extravasated  fluid,  amounting  to  nearly  a  pint, 
consisting  of  urine  and  blood,  was  carefully  removed  from  the  pelvis,  and 
between  the  convolutions  of  the  bowels.  A  rent  was  found  at  the  fundus 
of  the  bladder,  two  inches  in  extent  The  cavity  of  the  abdomen  being 
cleansed  of  the  noxious  agent,  the  wound  of  the  bladder  was  left  to  itself, 
as  no  urine  was  seen  to  escape  from  it.  .  The  abdominal  wound  was  closed 
by  strong  Carlsbad  needles,  secured  by  silver  wire  (only  skin  and  fascia 
being  stitched,  while  the  peritoneum  was  left  untouched) ;  a  flannel  band- 
age encircled  the  whole  abdomen.  The  patient  awakening  from  the  anaes- 
thetic sleep,  felt  relieved  of  pain  and  the  desire  to  urinate,  so  distressing 
before  the  operation  ;  vomiting  did  not  return  ;  opium  in  one-grain  doses 
was  ordered;  abstinence  of  drink  and  perfect  quietude  of  body,  with 

1  The  Medical  and  Surgical  Reporter,  Philadelphia,  February,  1862. 


WOUNDS    OF   THE   BLADDER.  371 

retention  of  the  catheter,  were  strictly  insisted  upon.  He  soon  began  to 
doze,  had  a  comfortable  night,  was  free  from  pain  the  next  morning,  com- 
plaining only  of  soreness  in  the  abdomen  without  tympanites,  sickness  or 
calls  to  urinate ;  thirst  less  urgent.  The  treatment  being  vigorously  con- 
tinued, for  drinks,  iced  barley-water,  water  only  in  very  small  quantities 
with  pieces  of  ice,  being  allowed.  No  unpleasant  symptom  followed ;  urine 
in  small  quantities,  but  free  of  the  admixture  of  blood  passing  by  the 
catheter.  On  the  third  day  the  intervals  between  the  doses  of  opium  were 
lengthened  to  two  hours ;  on  the  fifth,  to  three,  and  thus  gradually  de- 
creased, as  all  -signs  of  inflammation  had  passed.  At  the  end  of  a  week 
the  abdominal  wound  appeared  to  be  closed  by  first  intention ;  the  stitches, 
however,  were  not  removed  till  a  week  later.  The  gum-elastic  catheter 
was  replaced  by  a  new  one  every  two  days,  and  was  not  withdrawn  for  two 
weeks  after  the  injury  had  been  received,  and  then  only  for  a  short  time. 
At  the  expiration  of  two  weeks,  with  the  absence  of  all  pain  and  tender- 
ness, opium  was  omitted.  The  intestines  were  relieved  by  warm  water  in- 
jections on  the  tenth  day,  when  mild  nourishment  was  ordered.  Between 
the  second  and  third  week,  the  catheter  was  permanently  withdrawn  and 
introduced  only  every  four  hours  for  the  evacuation  of  urine.  After  the 
third  week,  the  patient  left  his  bed.  The  recovery  was  permanent,  so  that 
he  returned  to  his  work,  feeling  no  embarrassment  in  the  urinary  func- 
tions. 

In  two  other  recorded  instances,1  abdominal  incision  has  been  done  for 
the  removal  of  urine  extravasated  into  the  peritoneal  cavity.  In  both  those 
cases,  however,  the  operation  was  delayed  much  longer  than  in  the  case  of 
Walter,  until  dangerous  symptoms  were  well  developed.  Willett  operated 
thirty  hours,  and  Heath  forty-two  and  a  half  hours  after  the  injury.  In 
both  cases  suture  was  attempted,  but,  as  the  result  proved,  was  done  im- 
perfectly. In  4he  case  of  Willett,  the  patient  having  died  twenty-three 
hours  after  the  operation,  the  autopsy  showed  "  the  opening  in  the  bladder 
everywhere  well  closed  except  between  the  two  posterior  stitches  where 
there  was  an  orifice  through  which  water  injected  per  urethra m  escaped 
very  freely."  Heath's  patient  lived  more  than  four  days.  A  continuous 
catgut  suture  had  been  employed.  Autopsy  showed  that  it  had  given  way 

1  A.  Willett :  Abdominal  Section  in  a  Case  of  Ruptured  Bladder.  St.  Bartholo- 
mew's Hospital  Reports,  1876,  xii.,  pp.  209-222.  C.  Heath:  On  the  Diagnosis  and 
Treatment  of  Rupture  of  the  Bladder  Medico-Chirurgical  Transactions,  1879,  Ixii., 
p.  335. 


372  THE   TREATMENT    OF    WOUNDS. 

at  its  lower  end,  and  permitted  the  wound  in  the  bladder  to  gape  through- 
out the  lower  third  of  its  extent. 

The  advantages  offered  by  laparotomy  in  cases  of  wounds  of  the  intra- 
peritoneal  portion  of  the  bladder  are  thus  enumerated  by  Vincent : ' 
•  •  With  laparotomy  a  complete  examination  of  the  wounded  region  can  be 
made,  and  the  existence,  the  location,  the  extent,  and  the  conformation  of 
the  solution  of  continuity  experienced  by  the  urinary  reservoir  deter- 
mined ;  the  existence  and  nature  of  complications  can  be  seen,  if  a  vesical 
artery  is  wounded,  or  any  of  the  vascular  trunks  of  the  region  have  been 
torn,  they  can  be  ligated ;  if  intestinal  loops  have  been  perforated,  they 
can  be  sutured,  with  or  without  enterectomy  ;  if  the  rectum  has  been  per- 
forated— a  frequent  event — the  breach  which  is  found  can  be  sutured  ;  if 
a  splinter,  from  a  fracture  of  one  of  the  pelvic  bones,  projects  against  the 
bladder  and  is  tearing  it,  it  can  be  extirpated,  resected,  or  reduced,  as  the 
case  may  be  ;  if  a  foreign  body  has  remained  in  the  peritoneal  cavity,  it 
can  be  taken  away  ;  if  the  wounding  agent  has  lodged  in  the  walls  of  the 
bladder,  or  has  fallen  into  its  interior,  or  has  become  fixed  in  the  walls  of 
the  pelvis,  it  may  be  extracted  at  once,  which  will  prevent  those  fistula, 
those  suppurations,  those  lithic  concretions  which,  when  they  do  not  in- 
duce death,  necessitate  later,  sometimes  after  many  years  of  suffering,  re- 
course to  the  knife,  the  lithotrite,  or  the  lithotome.  With  laparotomy  the 
urine  can  be  completely  removed,  together  with  the  effused  blood,  all  the 
liquids  and  clots  which  may  be  found  in  the  peritoneal  cavity,  everything 
which  has  been  soiled  by  the  urine  can  be  disinfected  ;  in  a  word,  a  com- 
plete antiseptic  toilet  of  the  peritoneum  can  be  made  ;  with  laparotomy, 
finally,  the  source  of  urinary  extravasation  can  be  absolutely  suppressed 
by  careful  suture  of  the  bladder  ;  a  catheter  retained  in  the  bladder  can- 
not replace  the  suture,  this  is  evident." 

As  a  final  estimate  of  the  necessity  and  value  of  laparotomy  when  ex- 
travasation of  the  urine  into  the  peritoneal  cavity  has  taken  place,  the  fol- 
lowing is  the  conclusion  of  Stein  : " 

"  Both  clinical  and  experimental  experience  teach  that  the  danger  to 
life  is  not  in  the  laparotomy,  but  in  the  presence  within  the  peritoneal 
cavity  of  a  decomposable  and  septic  fluid,  and,  when  this  is  removed 

1  Plates  penetrantes  intraperitoneales  de  la  tessie.  Revue  de  Chirurgie,  1881,  i,  p. 
572. 

•  A  Study  of  Rupture  of  the  Bladder,  etc.  Annals  of  Anatomy  and  Surgery,  1882, 
vi.,  59. 


SUTURE  OF  THE  BLADDER.  373 

shortly  after  such  extravasation  has  occurred,  laparotomy  may  be  practised 
with  almost  a  certainty  of  success.  The  disposition  of  the  bladder-wound 
to  union  is  so  great  that  it  may  be  regarded  as  certain  if  the  edges  of  the 
same  are  accurately  brought  together,  while  the  danger  to  life  from 
wounding  of  the  peritoneum  is  in  itself  very  slight." 

When  an  intraperitoneal  wound  of  the  bladder  has  been  suffered,  the 
more  speedily  the  removal  of  the  intraperitoneal  extravasations  by  lapa- 
rotomy, and  the  closure  of  the  wound  by  suture,  is  effected,  the  greater 
will  be  the  probabilities  of  a  successful  issue.  Though  it  should  have 
been  delayed  until  severe  inflammatory  and  septic  conditions  have  already 
developed,  the  incision  of  the  abdominal  wall,  the  removal  of  effusions 
already  present,  free  irrigations  and  adequate  drainage,  may  still  afford  a 
possibility  of  recovery  from  what  would  otherwise  pursue  an  inevitably 
fatal  course. 

Suture  of  the  Bladder. — The  unfortunate  result  of  the  attempts  at 
suture  in  the  cases  of  "VVillett  and  of  Heath  may  serve  to  enforce  the  neces- 
sity of  caution  and  thoroughness  in  applying  the  suture  to  a  bladder- 
wound.  Vincent  (op.  citat.)  urges  the  adoption  of  the  method  of  a  double 
row  of  sutures,  one  at  the  edges  of  the  wound,  but  excluding  the  mucous 
coat,  and  another  row  which  pierces  the  serous  coat  a  little  distance  from 
the  edges  of  the  wound,  by  which  a  more  extensive  turning  in  and  appo- 
sition of  the  serous  membrane  is  accomplished.  This  is  the  method 
already  described  on  a  previous  page  (3G3)  as  Czerny's  modification  of 
Lembert's  suture,  which  see. 

The  double  row  of  sutures  closely  set  should  be  employed,  but  the 
suggestion  of  Nussbaurn,  in  connection  with  intestinal  wounds,  to  apply 
the  suture  as  a  continuous  suture  in  each  row,  should  be  followed,  on  ac- 
count of  the  greater  certainty,  ease,  and  speed  with  which  it  can  be  applied 
to  a  deep-seated  part  like  the  bladder.  Aseptic  silk  should  be  used  for 
the  ligature  material. 

The  number  of  cases  has  already  become  considerable  in  which  suture 
of  the  bladder  has  been  done,  with  recovery,  in  cases  of  wounds  of  t!;o 
bladder  inflicted  by  surgeons  during  the  removal  of  pelvic  and  abdominal 
neoplasms. 

CATHETEEIZATION. — Free  and  uninterrupted  drainage  of  the  bladder  \\v 
continuous  retention  of  a  catheter  in  the  bladder  through  the  urethra 
should   be  maintained   for  a  week   or  ten  days  after  the   injury. 
catheter  should  be  soft  and  flexible,  open  at  the  end,  and  its  end  should 


374  THE   TKEAT.MEST    OF    WOUNDS. 

reach  just  within  the  vesical  orifice.  It  should  be  removed,  washed,  and 
returned  once  daily  during  the  period  of  retention.  For  some  time,  a 
week  or  more,  after  its  continuous  residence  in  the  bladder  is  dispensed 
with,  it  should  yet  be  used  several  times  daily  to  remove  the  urine, 
during  which  time  no  effort  to  urinate  should  be  made  by  the  unaided 
contraction  of  the  bladder. 

WOUNDS  OP  ANUS  AND  RECTUM. — Wounds  involving  the  lower  end  of  the 
alimentary  canal  must  be  treated  as  open  wounds.  In  order  to  preserve 
them  from  sepsis  it  is  necessary  that  the  wound  cavity  be  kept  packed  with 
energetically  antiseptic  absorbent  material  and  that  the  function  of  defseca- 
tion  be  kept  in  abeyance.  The  lower  bowel  should  be  thoroughly  washed 
out  with  a  carbolic  or  corrosive  sublimate  solution,  and  the  movements  of 
the  bowels  checked  by  opium.  The  wound  itself  should  be  freely  irri- 
gated with  an  eight  per  cent,  solution  of  chloride  of  zinc,  after  which  the 
antiseptic  absorbent  selected  should  be  lightly  packed  into  the  wound  so 
as  to  reach  every  recess.  loioform  gauze,  bags  of  aluminated  charcoal  or 
sublimated  coal  ashes,  may  be  selected  according  to  the  convenience  of 
the  surgeon.  These  should  be  covered  in  by  a  plentiful  layer  of  purified 
cotton  wool,  over  which  a  layer  of  impermeable  tissue  should  be  placed, 
the  whole  kept  in  position  by  a  "f '-bandage.  Whenever  a  movement  of 
the  bowels  becomes  necessary,  sufficient  of  the  dressings  must  be  removed 
to  permit  the  issue  of  the  fsecal  matter,  after  wliich  the  bowel  should  be 
cleansed  and  the  wound  redressed  as  at  first.  When  the  wound  has 
become  a  superficial  granulating  surface,  the  rigid  antiseptic  efforts  may 
be  relaxed  and  the  sore  be  kept  smeared  simply  with  boracic  ointment. 


CHAPTER  XXL 

WOUNDS   OF  THE  EXTREMITIES— AMPUTATION. 

Limitations  of  Conservation — Classification  of  Wounds  possibly  demanding  Amputa- 
tion— Duty  in  Doubtful  Cases—  Period  for  Amputation — Primary,  Intermediary, 
and  Secondary  Periods  defined— Effect  of  Antiseptics  to  prolong  Primary  Period 
— Shock'a  Centra-indication — Amputation  to  be  done  during  Primary  Period — 
Point  of  Amputation — Treatment  of  the  Amputation  Wound. 

THERE  remain  for  presentation  some  considerations  as  to  the  management 
of  lacerated,  contused,  or  gunshot  wounds  of  the  extremities  in  which  the 
damage  is  so  extensive  as  to  compromise  the  vitality  of  the  parts  beyond 
the  wound  and  to  cause  the  question  of  amputation  to  be  entertained. 
Interest  centres  about  three  points,  viz. : — To  what  extent  should  attempts 
at  conservation  be  pushed,  and,  if  amputation  is  imperative,  when  and  at 
what  point  should  it  be  done  ? 

LIMITATIONS  OF  CONSERVATION. — In  deciding  to  what  extent  attempts  at 
conservation  should  be  pushed,  two  considerations  must  influence  the 
surgeon.  These  are  :  1.  Can  the  vitality  of  the  distal  portions  of  the 
limb  be  preserved  ?  and,  2.  If  preserved,  will  the  limb  be  a  useful  member 
or  a  useless  incumbrance  ? 

For  purposes  of  systematic  consideration  the  wounds  in  question  may 
be  divided  into  five  general  classes,  as  follows  : — 

1.  Injuries  in  which  the  whole  mass  of  the  limb,  to  a  variable  distance 
from  its  end,  is  mangled  and  pulpified,  or  torn  nearly  away. 

2.  Injuries  in  which,  at  a  limited  part  of  the  continuity  of  a  limb,  all 
the  tissues  in  its  whole  thickness  have  been  crushed. 

3.  Injuries  of  less  extent  but  in  which  the  great  vessels  of  an  extremity 
have  been  lacerated. 

4.  Injuries  characterized  by  open  wounds  communicating  with  exten- 
sively comminuted  bones  or  with  large  joint  cavities. 

5.  Injuries  characterized  by  extensive  stripping  away  of  soft  parts,  as 
integument  and  muscles. 


376  THE   TREATMENT    OF    WOUNDS. 

In  the  two  first  of  these  classes  the  duty  of  the  surgeon  is  plain  ;  prim- 
ary amputation  must  be  performed  ;  but  amputation  in  these  cases  is  to  be 
regarded  less  as  a  formal  operation  than  as  a  part  of  the  general  proced- 
ure of  the  primary  cleansing  of  the  wound  which  requires  that  devitalized 
tissues  shall  Be  removed  as  perfectly  and  speedily  as  possible  from  every 
wound. 

In  the  remaining  three  groups,  the  propriety  of  attempts  at  conserva- 
tion must  depend  on  the  facilities  at  the  command  of  the  surgeon  for  pre- 
serving the  wound  from  septic  infection  and  securing  to  it  perfect  rest 
during  repair,  and  upon  the  probable  future  usefulness  of  the  part,  if  am- 
putation is  avoided.  The  mere  wound  of  the  great  vessels,  unless  it  be 
attended  with  such  extensive  laceration  of  the  adjacent  soft  parts  as  to 
render  the  nutrition  of  the  distal  portion  of  the  limb  by  the  collateral  cir- 
culation obviously  improbable,  does  not  call  for  immediate  amputation. 
Wounds  of  the  joint  cavities  and  compound  comminuted  fractures,  in  the 
great  majority  of  cases,  can  be  conducted  to  recovery  by  adequate  measures 
of  disinfection,  drainage,  and  immobilization.  The  extensive  stripping 
away  of  soft  parts,  although  ultimate  cicatrization  of  the  wound  may  be 
possible,  may  nevertheless  be  a  sufficient  cause  in  some  cases,  for  primary 
amputation,  on  account  of  the  deformity  or  uselessness  of  the  part  which 
would  be  left 

Cases  will  present  themselves  in  which  the  question,  whether  the  vital- 
ity of  the  distal  portions  of  the  limb  can  be  preserved  or  not,  must  be  a 
doubtful  one,  and  will  depend  on  the  prevention  of  inflammatory  disturb- 
ances in  the  wound,  and  in  placing  the  endangered  portion  of  the  limb  in 
conditions  that  shall  favor  its  nutrition  as  perfectly  as  possible.  It  would 
be  incumbent  on  the  surgeon,  in  such  a  case,  to  make  the  effort  at  con- 
servation, and  to  resort  to  amputation  only  when  it  had  become  plain  that 
the  efforts  at  protection  were  unsuccessful,  or  that  the  vitality  of  the  en- 
dangered tissues  was  hopelessly  destroyed. 

PERIOD  FOB  AMPUTATION. — Wounds  in  which  the  accession  of  septic  con- 
ditions is  not  prevented,  have  their  history  divided  into  three  periods, 
primary,  intermediary,  and  secondary,  the  primary  being  that  short  period 
which  intervenes  between  the  reception  of  the  wound  and  the  appearance 
of  the  secondary  traumatic  fever  caused  by  the  development  of  septic  in- 
flammation in  the  wound,  a  period  generally  of  from  thirty-six  to  forty- 
eight  hom*s  ;  the  intermediary  period  being  the  period  during  which  pro- 
gressive local  inflammatory  infiltration  and  general  fever  prevail,  a  period 


THE    QUESTION    OF    AMPUTATION.  377 

extending  over  a  variable  time  ;  the  secondary  beginning  with  the  subsi- 
dence of  the  intermediary  stage,  as  marked  by  limitation  and  diminution 
of  the  infiltration  and  free  suppuration  from  the  wound  surfaces. 

When  adequate  antiseptic  measures  are  employed,  the  primary  stage  is 
indefinitely  prolonged,  inflammatory  infiltration  and  secondary  traumatic 
fever  are  prevented,  and  an  opportunity  afforded  for  the  full  display  of  the 
reparative  resources  of  the  injured  part. 

When  the  necessity  of  amputation  is  unquestionable,  it  should,  if  possi- 
ble, be  done  before  the  supervention  of  the  intermediary  stage.  If  this  has 
been  impracticable,  it  should  be  deferred  to  the  secondary  period,  unless 

progressive  gangrene  of  the  wound  develop,  when  amputation,  through 

i 
tissues  yet  sound,  should  be  done  as  quickly  as  possible.     Amputation 

should  never  be  done,  in  any  case,  until  full  reaction  from  the  shock  of  the 
original  injury  has  been  secured,  and,  if  such  reaction  is  delayed  until  the 
primary  stage  has  passed,  the  operation  must  be  deferred  yet  longer,  until 
the  secondary  stage  has  been  reached. 

The  prolongation  of  the  primary  stage  by  antiseptic  treatment — con- 
tinuous antiseptic  irrigation  being  the  method  which,  in  general,  is  best 
adapted  to  the  treatment  of  these  cases — makes  it  possible  for  the  surgeon 
to  delay  amputation  until  such  time  as,  in  his  judgment,  the  patient  will 
be  in  the  best  condition  to  bear  the  operation.  In  some  cases  it  will  hap- 
pily have  served  to  demonstrate  the  possibility  of  recovery  without  ampu- 
tation. In  cases,  the  possibility  of  saving  which  manifestly  depends 
entirely  upon  the  success  of  the  efforts  to  prevent  their  being  invaded  by 
septic  infection,  as  soon  as  it  is  evident  that  these  efforts  have  not  been 
successful,  amputation  should  be  proceeded  with  before  the  full  local  and 
constitutional  symptoms  of  the  sepsis  have  developed. 

POINT  OF  AMPUTATION. — The  choice  of  the  point  at  which  the  amputation 
shall  be  made  may  be  greatly  influenced  by  the  facilities  at  the  command 
of  the  surgeon  for  keeping  the  wound  aseptic.  If  these  be  adequate  for 
the  purpose,  the  section  may  be  made  at  whatever  point  may  be  desirable 
to  give  the  patient  the  most  useful  stump,  even  though  bruised  and  lacer- 
ated parts  be  included  in  the  flaps.  These  are  preserved  from  inflammatory 
disturbance,  their  full  vitality  is  regained,  and  they  participate  in  the  for- 
mation of  the  stump  without  disaster  from  sloughing.  When,  for  any  rea- 
son, the  wound  cannot  receive  adequate  antiseptic  treatment,  amputation 
will,  if  possible,  be  made  at  a  point  sufficiently  far  above  the  injury  to  ex- 
clude all  bruised  and  lacerated  tissue  from  the  flaps. 


378  THE   TREATMENT    OF    WOUNDS. 

TREATMENT  OF  THE  AMPUTATION-WOUND. — In  the  treatment  of  the  wounds 
made  by  amputation,  scrupulous  attention  should  be  paid  to  all  the  details 
of  treatment  which  have  been  dwelt  upon  in  the  chapters  on  the  "  Practice 
of  Wound-Treatment "  in  the  first  part  of  this  work.  Absolute  aseptic 
cleanliness  of  everything — hands,  instruments,  dressings, — that  is  brought 
in  contact  with  the  wound  ;  perfect  arrest  of  haemorrhage  by  catgut,  cut 
short  after  being  securely  knotted ;  ample  provision  for  drainage  from  the 
deepest  recesses  of  the  wound  ;  thorough  disinfection  of  the  wound  sur- 
faces ;  careful  apposition  of  the  flaps  by  both  deep  and  superficial  sutures ; 
protection,  support,  and  compression  by  external  antiseptic  dressings  ;  an 
elevated  and  comfortable  position  for  the  stump  and  protection  of  the  limb 
from  motion  or  external  traumatism  of  any  kind,  these  constitute  the  in* 
dications  to  be  observed.  The  various  means  by  which  they  may  be  met 
have  been  sufficiently  pointed  out  The  adaptation  of  the  particular 
agents  to  each  special  case  must  be  left  to  the  judgment  of  the  surgeon. 


INDEX, 


ABERNETHY,  on  ligatures,  106 
Abdomen,  wounds  of,  351 
Abdominal  viscera,  protrusion  of,  353 
Abscesses,  metastatic,  49 
Absorbable  drainage-tubes,  146 
Absorbent  cotton,  184 
gauze,  186 

Absorption  of  subcutaneous  effusions,  238 
Achilles-tendon,  suLure,  272 
Acupressure,  99 

in  vein-wounds,  592 

to  compre-s  vessels  in  their 

continuity,  125 
Adhesion,  union  by  primary,  27 

union  by  secondary,  29 
Adhesive  gauze,  190 
plaster,  162 

Afflux,  physiology  of,  24 
Age,  modifying  the  effects  of  wounds,  13 
AGNEW,  D.  H.,  on  mediate  ligation  of  an 

intercostal  artery,  344 
Air,  both  an  antiseptic    and  a  carrier  of 

contagion,  18 

exposure  to,  as  an  haemostatic,  95 
impure,  effect  of,  on  wounds,  18 
of  Paris,  germs  in,  39 
purification,  66,  68,  156 
varying  degrees  of  purity  of,  in  differ- 
ent localities,  66 

ALBANESE,  on  penetrating  incised  wounds 
of  the  abdomen,  354 
of  the  chest,  345 
on  treatment  of  incised  wounds, 

241 

Albuminates,  zinc  and  phenol,  81 
Alcohol,  haemostatic  effects  of,  97 

strength     required     to     restrain 
germ-development,  72 


ALLJS,  O.  H.,  on  lateral  ligation  of  inter- 
nal jugular  vein,  340 
Alum,  as  an  haemostatic,  118 
Alumina,    acetate   and   aceto-tartrate,    as 

antiseptics,  83 
Alurniuated  charcoal,  1!)2 
Ammonium  chloride  as  a  sorbefacient,  2C9 
AMUSSAT,  on  torsion,  115 
Amputation,  375 
Amputations,  comparative  table  of  septic 

and  aseptic  cases,  55 
Amputation-wounds,  treatment  of,  378 
Anaemia,  from  haemorrhage.  1 2!) 
Anaesthetics,   parallel   between,  r.nd  anti- 
septics, C9 

Anal  region,  micro-organisms  infesting,  64 
wounds  of,  use  of  alumiuated 

charcoal  in,  84 

Aneurism,  diffuse  traumatic,  288 
Animal  ligatures,  108 
Anodynes,  216 

after  haemorrhage,  126 
Anthrax  infection  from  catgut,  78 
Antisepsis,  61 

Antiseptic  bath  for  instruments  and  appli- 
ances, 155 
dressings,  184 
sprays.  67 
tampons,  248 

treatment,  results  of,  54,  C7 
Antiseptics,  69 

definition  of,  60 
in  erysipelas,  229 
Anus,  wounds  of,  374 
Apparatus  for  irrigation,  141,  222 
Apposition,  defects  of.  analyzed.  "27 

in  wounds  of  abdominal   pari- 
etes,  352 


380 


INDEX. 


Apposition,  in  wounds  of  blood -vessels,  282 

peritoneum,  353 

of     contused    and    lacerated 

wounds,  244 
divided  nerves,  273 
divided  tendons,  271 
incised  wounds,  241 
wound-surfaces,  160 
Approximation  stitches,  165 
Arrest  of  haemorrhage,  93 
Arsenic,  power  as  a  germicide,  73 
Arsenite  of  potassa,  power  as  a  germicide, 

71 

Arteries,  effects  of  torsion  on,  116 
wounds  of,  280 

carotid,  315,  337 
intercostal,  344 
internal     mammary, 

342 
middle      meningeal, 

314 

vertebral,  338 
Artery  forceps,  112 
Asepsis,  60 

how  obtained,  61 
Aseptic  ligatures,  112 

in  vein-wounds,  293 
sponges,  139 
wounds  defined,  11 

Atmospheric  organisms,  causes  of  decom- 
position, 38 

Auto-transfusion  of  blood,  129 
AvELDsG,  apparatus  for  direct  transfusion 

of  blood,  136 

Axilla,  micro-organisms  infesting,  64 
Axillary  vein,  lateral  suture  of,  298 


BACILLI,  41 

Bacteria,  41 

Bandage,  elastic,  tourniquet,  124 

Bandages,  197 

adhesive,  application  of,  163 

adhesive,  objections  to,  164 

for  the  head,  318 

in  the  treatment  of  inflamma- 
tion, 220 

plaster-of-Paris,  211 

Bandaging,  as  a  means  of  apposition,  161 
Base  of  the  skull,  fractures  of,  311 
Bath,  antiseptic,  for  instruments  and  ap- 
pliances, 155 


Bavarian  splint,  208 

Bead  suture,  179,  182 

BELFIELD,  on  effects  of  micro-organisms, 

45 

on  the  causes  of  septicaemia,  49 
BELL,  C.,  illustrations  of  trephining,  326, 

328   . 

BELL,  JOHN,  discourses  on  wounds,  4 
BERGMANN,  on  the  causes  of  septicaemia,  49 
BILLBOTH, method  of  dressing  wounds.  200 
on  causes  of  septicaemia,  49 
on  suture  threads,  167 
on  turpentine  as  an  haemostatic, 

97 

Birth,  wounds  during,  318 
Bismuth  cotton,  186 

intoxication,  89 

subnitrate  of,  as  an  antiseptic,  88 
Bladder,  protrusion  of,  356 
suture  of,  373 
wounds  of,  3G9 
Bleeding  in  head-injuries,  312 
BLOCK,  on  resection  of  the  lungs,  047 

on  surgical  interference  with  the 

heart,  346 

Blood,  abstraction  of,  in  inflammation,  225 
Blood-clots,  how  disposed  of,  31 

when  to  be  left  undisturbed, 

62 

Blood-poisoning,  49 

Blood-supply  of  inflamed  parts,  how  in- 
terrupted, 225 

Blood-vessels,  wounds  of,  280 
BCECKEL,  R,  on  hypodermics  of  carbolic 

acid  in  erysipelas,  230 
BOILLAT,     experiments    with    zinc,    and 

phenol  albuminates,  81 
Bone  drainage-tubes,  decalcified,  146 
Boracic  acid,  as  an  antiseptic,  83 

power  as  a  germicide,  71 
power  in   restraining  germ- 
development,  72,  73 
Boratcd  cotton,  185 

Borax  (biborate  of  sodium),  strength  re- 
quired to  restrain  germ-development, 
72,73 

Bowels,  micro-organisms  infesting,  64 
Brain,  compression  of,  313 

wounds  of,  315 

BHATTN,  on  lateral  ligation  of  veins,  296 
BRIGGS,  W.  T. ,  on  trephining,  321 
Bromine,  power  as  a  germicide,  73 


INDEX. 


381 


BRUNS,   P.,    on   acetate   of  alumina    for 

continuous  irrigation,  228 
on   treatment   of    compound 

fractures,  257 

BRUNS,  TON,  on  carbolated  gauze,  189 
t-poon  curettes,  158 
on  wood-wool,  194 
BRYANT,  T. ,  on  iodine,  84 
on  torsion,  115 
on   treatment   of  punctured 

wounds,  246 

Buffalo-tendon  ligatures,  109 
Bullets,  removal  of,  249,  252,  253 
Button  suture,  180 

CAMPBELL,  H.  F.,  on  ligation  of  artery  of 

supply  in  treating  inflammation,  226 
Canula,  tracheal,  335 
Capelline  bandage,  319 
Capillary  drainage,  148 
Carbolated  cotton,  186 
gauze,  187 
Carbolic  acid,  as  an  antiseptic,  76 

hypodermics   of,  in    erysip- 
elas, 230 
intoxication,  80 
local  irritation  caused  by,  79 
lotions,  77 

power  as  a  germicide,  71 
strength  required  to  restrain 

germ-development,  72 
volatility  of,  79 

Carbolic  gauze,  rapid  deterioration  of,  79 
oil,  78 
sprays,  67 

Cardiac  sedatives,  126 
Caribou- tendon  ligatures,  109 
Carotid  arteries,  wounds  of,  337 
Carotid  artery,  internal,  wounds  of,  315 
Catgut,  anthrax  infection  from,  78 
drains,  148 
ligatures,  109 
sutures,  168 
Catheterization  in  wounds  of  the  bladder, 

373 

Cautery,  118 

Cell-germination,  physiology  of,  25 
Cerebri,  hernia,  317 
Changes  of  dressings,  214 
Charcoal,  192 
CllASSAIGNAC,  on  drainage,  145 

on  ligation  of  veins,  290 


CIIAULIAC,  GUY  DE,  on  drainage,  144 
CIIEYNE,  description  of  Lister's  method 

of  wound-dressing,  198 
on  carbolated  gauze,  187 
on  different   species   of  micro- 
organisms, 42 
on  "the  protective,"  196 
results  of  antiseptic  treatment, 

57 

Chicken-bone  drainage-tubes,  147 
CHIENE,  on  catgut  drains,  148 
Chloral   hydrate,  power  as   a  germicide, 

71 

Chloride  of  zinc,  as  an  antiseptic,  81 
Chlorine,  power  as  a  germicide,  73 
Chromicized  catgut  ligatures,  110 
Cicatrization,  physiology  of,  26 
Citric  acid,  power  as  a  germicide,  71 
Classification  of  compound  fractures,  256 
of  gunshot  wounds,  250 
of  wounds,  8 
Cleanliness,  of  adjacent  tissues,  64 

scope  of  the  term,  62 
Cleansing  compound  fractures,  257,  258 
contused  and  lacerated  wouiids, 

243 

gunshot  wounds,  247 
peritoneal  cavity,  ^67 
primary,  of  wounds,  62 
wounds,  138 

Cloth  for  plaster -of -Paris  splints,  211 
Clothing  of  surgeon,  to  be  purified,  155 
Coagulants,  118 
Coal-ashes,  193 
Coaptation  stitches,  165 
Coils,  water,  in  inflammation,  223 
Cold,  application  of,  in  the  treatment  of 

inflammation,  220 
as  an  haemostatic,  96 
COLLIN,  instrument  for  transfusing  blood, 

132 
Collodion,  163 

iodoform,  201 
Compound  fractures,  255 
Compresses,  cold,  in  inflammation,  220 
haemostatic,  98 
materials  for,  162 
warm  and    moist,   in  inflam- 
mation, 225 
Compression,  as  an  haemostatic,  97 

in  the  treatment  of  inflam- 
mation, 219 


382 


INDEX. 


Compression,  in  the  treatment  of  wounds, 

206 
in  wounds  of  blood-vessels, 

282 

of  the  brain,  312 
of  parent   trunk   to    arrest 

haemorrhage,  119 
Constitutional    conditions,   as    modifying 

the  eifects  of  wounds,  14 
Cpnstitutional  effects  of  wounds,  21 
Continuous  suture,  174 
Contused  punctured  wounds,  245 
Contused  wounds,  242 
Contusions,  22 

of  the  scalp,  302 
of  the  skull,  308 
Cooling  coils,  224 

COOPER,  AST-LEY,  on  ligatures,  106,  109 
Corrosive  sublimate,  antiseptic  properties 

of,  74 

power    as    a    germi- 
cide, 71,  72 
strength  required  to 
restrain    germ-de- 
velopment, 72 
Cotton  wool,  184 
Court  plaster,  163 
Cranial  nerves,  injuries  to,  315 
Cranium,  injur.es  to,  307 
Creosote,  power  as  a  germicide,  71 
Cupping,  in  inflammation,  225 

«    in  subcutaneous  injuries,  239 
CZERNY,  case  of  lateral  suture  of  internal 

jugular  vein,  298 
Czerny's  suture,  363 


DAVY'S  LEVEU  for  compressing  iliac  artery 
through  the  rectum,  122 

Dead  tissue,  how  disposed  of,  31 

Decomposition  a  cause  of  inflammation,  36 
causes  of,  38 

Deer-sinew  ligatures,  109 

Defects  of  apposition  analyzed,  27 

of  nutrition  analyzed,  28  ' 

of  protection  analyzed,  28 

Defibrination  of  blood,  134 

Definition  of  wounds,  7 

DESAUI/T,  on  ligatures,  106 
tampon  of,  343 

Diastasis  of  cranial  sutures,  311 

DIEFFENBACH,  needle-holder  of.  166 


Digital  compression  of  parent  trunk  to  ar- 
rest hasmorrhage,  119 
Disease,  pre-existing,  as  modifying  the  ef- 
fects of  wounds,  15 
Disinfection  of  skin,  necessity  for,  65 
Disturbances  of  healing,  relief  of,  218 
of  repair,  destructive,  33 
Douches  of  hot  water,  as  a  sorbefacient, 

239 
Drainage,  143 

artificial,  144,  151 

capillary,  148 

definition  of,  63 

in  compound  fractures,  259 

natural,  143 

of      contused      and     lacerated 
wounds,  244 

of  incised  wourds,  241 

of  peritoneal  cavity.  367 

of  pleural  cavity,  349 

primary  ,152 

secondary,  153 

tubular,  145 

when  unnecessary,  63 
Drainage-tubes,  145 

for  empyema,  349 
Dressings,  antiseptic,  184 

external,  to  be  purified,  156 

iodoform.  of  Bill  roth,  200 

Lister's  method,  198 

of  wound,  defined,  66 

subsequent.  214 

turf -mould  of  Esmarch,  203 
DUNCAN,  JOHN,  observations  of  impurities 

in  the  air.  67 

DUPUYTREN,  on  ligation  of  veins,  290 
DUHOY,  on  iodine,  84 
Dust,  38 

EAR,  wounds  of,  330 

Ears,  micro-organism-  infesting,  64 

Effusions,  subcutaneous,  238 

Embryonic  reversion  of  tissue,  26 

Emmert's  suture,  362 

Emphysema.  348 

Empyema,  348 

ERICHSEN,  on  the  effects  of  diet  on  the 

repair  of  wounds,  15 
on  effects  of  overcrowding,  19 
on  ligation  of  veins.  290 

Erysipelas  of  the  scalp,  305 
treatment  of,  228 


INDEX. 


383 


ESMARCH,   apparatus   for    transfusing  by 

hydrostatic  pressure,  134 
on  antiseptic  use  of  corrosive 

sublimate,  75 
on   enlarging  openings   in  cal- 

varia,  325 

on    exposing  wounded    blood- 
vessels, 284 
on    plaster-of-Paris   bandages, 

211 

the  turf -mould  dressing,  203 
use  of  elastic  bandage  to  com- 
press blood-vessels,  125 
Evaporating  lotions,  221 
EVE,  P.,  on  deer-sinew  ligatures,  109 
Experiments  on  effects  of  ligatures  on  re- 
pair of  vein-wounds,  293 
Exploration  of  abdominal  cavity,  356 

of  gunshot  wounds,  249,  252 
Extremities,  wounds  of,  375 
Exudation,  p'.iysiology  of,  25 
Eye,  wounds  of,  330 
Eyelids,  wounds  of,  330 

FACE,  wounds  of,  330 

FEIILKISEN,  on  micrococci  of   erysipelas, 

44,  229 

Femoral  vein,  lateral  suture  of,  298 
Fenestrated  plaster  splints,  211,  265 
Fever  of  reaction,  22 

traumatic,  22 

FIELDING,  on  silkworm-gut  ligatures,  109 
FISCHER,  E. ,  on  naphthalin,  b7 
FISCHER,  on  wounds  of  the  heart,  346 
Flexion,  forced,  in  treating  inllammation, 

226 

•  to  arrest  haemorrhage,  119 

FLOURENS,  on  nerve-grafting,  278 
Fluids,  irrigating,  143 
Fomentations,  225 
Food,  as  modifying  the  effects  of  wounds, 

-•5 
Forceps,  haemostatic,  102 

torsion,  117 
Forcipressure,  100 

in  vein-wounds,  292 
Four-tailed  cap  bandage,  320 
FOWLER,  G.  R.,  on  naphthalin,  88 

in  naphthalinated  gauze,  190 
Fox -tail-tendon  ligatures,  109 
Fractures,  compound,  255 

of  nasal  bones,  330 


Fractures,  of  (he  skull,  309 
Function,  impairment  of,  23 

GAINE,  A.  D.,  Needle-holder  of,  167 
GAFFKY,  on  the  relation  of  micro-organ- 
isms to  septicaemia,  50 
Gangrene,  spreading,  cause  of,  45 

treatment  of,  227 
Gaping,  23 
Gauze,  186 

bandages,  197 
GELY,  the  suture  of,  362 
GENZMER,  on  entrance  of  air  into  intra- 

cranial  sinus,  313 
Germs,  38 
Germ-development,    strengths   of  various 

re -agents  required  to  restrain,  72 
Germicidal  strengths  of  various  re-agents, 

71 

GERSTER,  A.  G. ,  on  lateral  ligation  of  in- 
ternal jugular  vein,  340 
Glover's  suture,  174 
GLUCK,  on  neuroplasty,  278 
Gold-beater's  skin.  163 
Grafting,  nerve,  278 
Granulation,  healing  by.  29 
Granulation-polypi,  mtertracheal,  335 
Granulations,  29 

GRKENE,  W.  W.,  on  boracic  acid,  83 
GROSS,  S.    D.,  case  of  wound   of  internal 

jugular  vein,  295 
on  after-treatment  in  cases 

of  haemorrhage,  126 
on     ligating     a     wounded 

artery,  283 
GTTii.LEMEAr,  on  the  use  of  the  ligature, 

105 
Gunshot  wounds.  247 

classification  of.  250 
of  abrlomen,  357 
of  brain.  316 
of  chest,  345 
of  face,  331 
of  oesophagus,  336 
of  scalp,  306 
GUSSEXBAUER,  the  suture  of,  303 

HAEMORRHAGE  after   extraction  of  teeth. 

331 

arrest  of,  93 
deaths  from,  280 


384 


INDEX. 


Haemorrhage,    general  considerations  on, 

24 

intermediary,  285 
in  abdominal  wounds,  351 
in  contused  and  lacerated 

wounds,  242 
in  gunshot  wounds,  247 
in  incised  wounds,  240 
intraperitoneal,  359 
into  pleural  cavity,  348 
into  trachea,  335 
primary.  285 
secondary,  287 
subcutaneous,  237 
Haemostasia,    spontaneous,   how   effected, 

94 

Haemostatic  forceps,  102 
Haemothorax,  348 
Halter  bandage,  319 

HAMILTON,  F.  H. ,  on  continuous  submer- 
sion in  hot  water,  142 
on   hot   water    as    an 

haemostatic,  90 
Hands  of  surgeon,  method  of  purifying, 

154 

Hare-lip  suture,  175 
Head,  bandages  for,  318 
-net,  320 
wounds  of,  301 
Healing  by  first  intention,  27 
by  granulation,  29 
by  scabbing,  30 
by  second  intention.  29 
disturbed,  means  of  relief,  218 
Heart,  wounds  of,  346 
Heat,  reduction  of,  in  the   treatment  of 

inflammation,  220 
HEATH,  C.,  case  of  laparotomy  for  wound 

of  bladder,  371 
Hernia  cerebri,  317 

of  the  lung,  347 
HEWSON,  ADDINELL,  on  the  effect  of  the 

weather  on  wounds,  16 
Honeycomb  plaster  splint,  266 
Horse-hair  drains,  150 
sutures,  169 

Hot  climates,  healing  of  wounds  in,  16 
Hot   water  douches,    as    a    sorbefacient, 

239 
HuETEK,  on  arterial  transfusion,  136 

on  hypodermics  of  carbolic  acid 
in  erysipelas,  230 


HUMPHREY,  G.  M.,  on  the  importance  of 
wound-treatment.  3 

HUNT,  WM.  ,  views  on  micro-organism,  47 

HUNTER,  C.  T.,  on  hot  water  as  an  hae- 
mostatic, 96 

saw  for  removing  plaster  splints, 
215 

Hydrochloric  acid,  power  as  a  germicide, 
71 

Hydrostatic  pressure  as  a  means  of  trans- 
fusing blood,  131 

Hydrothorax,  348 

Hygienic  conditions,  as  modifying  the  ef- 
fects of  wounds,  15 

Hyperaemia,  active,  physiology  of,  24 

Hypodermics  of  carbolic  aeid  in  erysipelas, 
230 

ICE-BAGS,  in  inflammation,  223 

Ichthyocolla  plaster,  163 

Idiosyncrasy   as  modifying  the   repair  of 

wounds,  12 

Immersion,  in  inflammation,  222 
Immobilization,  206 

in    compound    fractures, 

and  joint-wounds,  262 
in  gunshot  wounds,  254 
in  inflamed  wounds,  219 
Impairment  of  function,  23 
Impermeable  envelope,  external,  196 
Incised  wounds,  240 

of  the  scalp,  303 

Incisions,  in  the  treatment  of  inflamma- 
tion, 219 
in  inflamed  punctured  wounds, 

246. 
Inflammation,  causes  of,  35 

.  note  as  to  use  of  the  lerm, 

28 

of  incised  wounds,  242 
of    subcutaneous    wounds, 

240 

pathology  of,  34 
treatment  of,  218 
Instruments,  how  purified,  155 
Intention,  union  by  first,  27 

union  by  second,  29 
union  by  third,  29 
Intercostal  artery,  wounds  of,  344 
Intermediary  haemorrhage,  285 
Interrupted  plaster  splints,  212,  266 
suture,  174 


INDEX. 


385 


Interruption  of  blood-supply  to  inflamed 

parts,  225 

Intestinal  wounds,  suture  of,  360 
Intestine,  protrusion  of,  355 
Intra-cranial  vessels,  wounds  of,  313 
Iiivaginated  bandage,  161 
Invagination  suture  of  Jobert,  364 
Iodine,  as  an  antiseptic,  84 
as  an  haemostatic,  97 
lotions,  84 

power  as  a  germicide,  71,  73 
power  in  restraining  germ-develop- 
ment, 72 

lodoform,  as  an  antiseptic,  85 
collodion,  201 
cotton,  186 
dressings,  200 
gauze,  189 
intoxication,  86 

Iron,  chloride  of,  power  as  a  germicide,  73 
tincture  of,  power  as  a  germicide,  71 
subsulphate,  as  an  haemostatic,  118 
sulphate,  power  as  a  germicide,  71 
power  in  restraining  germ-develop- 
ment, 72 
Irrigation,  141 

continuous,  of  septic  wounds, 

228 

cool,  in  inflammation,  221 
fluids  for,  143 

of    contused     and     lacerated 
wounds,  244 

JAMESON,  on  ligatures  of  buckskin,  108 
JOBERT,  the  suture  of,  361,  364 
Joints,  wounds  of,  255,  259 
JONES,  J.  F.  D.,  on  hasmostasis,  106 
Jugular    vein,  internal,    wound    of,    292, 

295,  298,  339 

Juniper,  oil  of,  for  catgut  ligatures,  111 
Jute,  191 

KANGAROO-TAIL-TENDON  ligatures,  109 

KEATE,  ligation  of  middle  meningeal  ar- 
tery, 314 

KEETLEY,  on  hofc  water  as  an  haemostatic, 
96 

KEITH,  on  drainage  of  peritoneal  cavity, 

'    368 

Kidney,  protrusion  of,  356 

KLEBS,  experiments  on  suppuration  and 
septicaemia,  45,  50 


Knee-joint,    antiseptic    excisions  of,    by 

Stokes,  57 
Knots,  suture,  173 
KOCH,  micrococcus  of  gangrene  in  mice, 

44,  50 

on  carbolic  oil,  78 

results  of  experiments  with  germi- 
cides, 72 

KOCHER,  anthrax  infection  from  catgut,  78 
on    irrigation   with   dilute  solu- 
tions of  chloride  of  zinc,  82 
on  oil  of  juniper  for  catgut  liga- 
tures, 111 
on  plugging  a  wounded  vertebral 

artery,  338 
on  secondary  suture  in  treatment 

of  wounds,  144 
on  subnitrate  of  bismuth,  88 
KOEBERLE,  on  forcipressure,  101 
KOENIG,  case  of  excision  of  the  sternum, 

346 
KOPFF,    deterioration     of    carbolic    acid 

dressing,  79 

KUMMELL,  H.,  on   aceto-tartrate   of    alu- 
mina, 84 

on  antiseptic  use  of  corro- 
sive sublimate,  75 
on  preparation  and  use  of 
aluminated  charcoal,  192 
on  spun-glass  drains,  150 
KUSTER,  on  hypodermics  of  carbolic  acid 
in  erysipelas,  231 


LACERATED  wounds,  242 

of  the  scalp,  303 
Lacerations,  22 
LANGE,  F.,  case  of  tendon-suture,  272 

case  of  lateral  ligation  of  inter- 
nal jugular  vein,  340 
LANGENBECK,  case  of  wound  of  internal 

jugular  vein,  295 
effects    of    immersion     of 
wounds  in  warm   water, 
143 

on  ligation  of  veins,  290 
Laparotomy,  explorative,  for  intraperiton- 
eal  wounds  of  bladder,  372 
for   wounds    of    abdominal 

viscera,  356 

Larynx,  wounds  of,  333 
Lateral  ligation  of  veins,  295 


386 


INDEX. 


Lateral  ligature  of  internal  jugular  vein, 

339 

Lateral  suture  of  veins,  298 
Lead  suture-buttons,  181 
Leeches,  in  inflammation,  225 
LEITER,  tubes  for  water  coils,  223 
LEMAIRE,  the  first  to  employ  carbolic  acid 

in  wounds,  76 
LEMBERT,  suture  of,  360 
LIDELL,  on  deaths  from  haemorrhage,  280 
on  lateral  ligation  of  internal  jug- 
ular vein,  340 

on  wounds  of  the  vertebral   ar- 
teries, 338 
Ligation  of  artery   of  supply,  in  treating 

inflammation,  226 
of  bleeding  vessels,  104 
of  veins,  290 

of  vessels  in  their  continuity,  126 
technique  of,  112 
Ligatures,  aseptic  catgut,  110 
aseptic  silk,  112 
in  wounds  of  blood-vessels,  283 
lateral,     of      internal    jugular 

vein,    339 

.  materials  for,  107 
substitutes  for,  107 
Lime,  chloride  of,  known  as  a  germicide, 

73 

Lint,  191 

Lips,  micro-organisms  infesting,  64 
LISTER,  J.,  and  carbolic  acid,  76 

case  of  lateral  suture  of  ax- 
illary vein,  298 
on  catgut  ligatures,  110 
on    drainage     of    peritoneal 

cavity,  367 

on  lead  suture -buttons,  181 
on     method      of     dressing 

wounds,  198 

on  primary  drainage,  152 
on     "protective"    material, 

195 

results    of    antiseptic  treat- 
ment, 54 
use    of   spray  to  purify  air, 

67 

LTSFRANC,  on  ligation  of  veins,  290 
LITTLE,   results  of  antiseptic  treatment, 

57 

Liver,  protrusion  of,  355 
Local  effects  of  wounds,  22 


L5FFLER,  on  the  relation  of  micro-organ- 
isms to  septicaemia,  50 
Longitudinal  sinus,  wound  of,  313 
LOWER,  apparatus  for  transfusion,  137 
Lungs,  resection  of,  347 
wounds  of,  346 

MAAS,  on  acetate  of  alumina,  83 
MAC  CORMAC,  on  compound  fractures,  256 
on  drainage-tubes,  152 
on  gunshot  wounds,  248 
on  horsehair  drains,  150 
on  the  preparation  of  plas- 

ter-of -Paris  splints,  210 
MACEWEN,     on     chicken-bone     drainage 

tubes,  147 

on  horsehair  drains,  150 
results  of  osteotomies,  56 
Macintosh  cloth,  196 
MALGAIGNE,  on  lateral  ligation  of  veins, 

296 

Mammary  artery,  internal,  wounds  of,  34£/ 
MARCY,  H.  O.,  on  animal  ligatures,  109 
Marine  lint,  191 

MARKOE,  on  "  through  drainage,"  153 
MARTIN,  H.  A.,  adhesive  plaster,  162 
rubber  bandage,  197 
MASON,  L.    D.,   method  for  fracture   of 

nasal  bones,  330 
Massage,  239 
MAUNDER,  on  ligation  of  artery  of  supply 

in  treating  inflammation,  227 
McSwEENET,  on  silkworm-gut  ligatures, 

109 

Median  nerve,  suture  of,  275,  277 
Mediate  ligation,  105,  113 
Meningeal  artery,  middle,  wounds  of,  314 
Mental  states,    as   modifying    repair    of 

wounds,  12 
influence  of,  over  body, 

13 
Mercuric    bichloride,    antiseptic  uses  of, 

74 

power  as  a  germi- 
cide, 71,  72 
power   in  restrain- 
ing   germ-devel- 
opment, 72 
Metal  sutures,  169 
Micrococci,  41,  42 

and  suppuration,  46 
Micrococcus-poisoning,  51 


INDEX. 


387 


Microorganisms  infesting  various  regions 

of  the  body,  64 
relations  of,  to  disease,  45 
relations  of,  to  wound-dis- 
turbances, 58 
species  of,  40 
unaffected     by    carbolic- 
spray.  67 

MILLER,  on  ligation  of  veins,  290 
MIQUEL,  experiments  on  the  air  of  Paris, 

39 
Modifying  influences,   repair  of   wounds, 

12 

MONSEL,  the  salt  of,  118 
Moose-tendon  ligatures,  109 
MosETiG-MooRHOF,  on  iodoform,  85 
Mouth,  wounds  of,  332 
Mucous  orifices,  wounds   of,  difficulty   in 

preserving  aseptic,  65 
Muriate  of  ammonia  lotion  as  a  sorbefa- 

cient,  239 
Muscles,  wounds  of,  269 

NAPHTHALIN,  as  an  antiseptic,  87 

in  erysipelas,  231 
Naphthalinated  cotton,  186 
gauze,  190 
oakum,  191 

Nasal  bones,  fract  -res  of,  330 
Nationality,     as     modifying     repair     of 

wounds,  12 
Neck,  wounds  of,  333 
Necrosis,  34 
Needle-holders,  166 
Needles,  acupressure,  99 
for  suturing,  165 

NELATON,  on  wounds  of  internal  mam- 
mary artery,  342 
NELSON,  S.  N.,  on  cloth  fabric  for  plastic 

splints,  211 
Nerve  grafting,  278 

suture,  274,  276 
Nerves,  cranial,  injuries  to,  315 

wounds  of,  273 
Net  for  head,  320 
NEUBER,   on    absorbable  drainage-tubes, 

146 
on  antiseptic  uses  of  corrosive 

sublimate,  75 
on  iodoform,  87 
on  use  of  turf-mould,  192 
Neuroplasty,  278 


NICAISE,  on  neuroplasty,  278 
NIGHTINGALE,  FLORENCE,  on  the  effects 

of  sunlight,  17 

Nose,  micro-organisms  infesting,  64 
NUSSBAUM,  antiseptic  results  obtained  by, 
55 

on  erysipelas,  229 
on  intestinal  sutures,  364 
Nutrition,  defects  of,  analyzed,  28 

OAKUM,  191 

Occlusion,  primary  antiseptic,  of  gunshot 

wounds,  248 

(Esophagus,  wounds  of,  336 
OGSTON,  A.,  on  different  species  of  micro- 
organisms, 41,  43 
on  micrococcus-poisoning,  52 
on  the  relation  of  micrococci 

to  suppuration,  46 

O'HALLERAN,  on  healing  of  wounds,  5 
OLLIER,  en  thrombosis  of  veins,  290 
Omentum,  protrusion  of,  355 
Open  method  of  treating  wounds,  144 
Open  wounds  defined,  9 

iodoform  dressing  of  ,201 
Opiates,  216 

Opium  after  haemorrhage,  126 
Osmic  acid,  power  as  a  germicide,  73 
Osteotomy — Macewen's  results  in,  56 
OTIS,   G.   A.,   on   the   use   of   sutures   in 
wounds  of  the  abdominal  parietes,  352 

PAGE,  H.  W.,  on  suturing  nerves,  275 
PAGET,  on  exposure  to  air  as  a  cause  of 

inflammation,  35 
on  influence  of  age  on  effects  of 

wounds,  13 
Pain,  23 

PANUM,  on  the  causes  of  septicasmia,  49 
on  value  of  defibrinated  blood  for 

transfusion,  134 
Paraffine  paper,  197 
PAR£,  at  the  siege  of  Metz,  20 

on  the  use  of  the  ligature,  104 
PARK,  R. ,  on  naphthalin,  88 

on  naphthalinated  gauze,  190 
PARKER,  on  wound  of  middle  meningeal 

artery,  314 

PARKES,  C.  T.,  case  of  wound  of  longitu- 
dinal sinus,  313 
on  lateral  ligation  of  in- 
ternal jugular  vein,  340 


388 


INDEX. 


Particles,  germinal,  38 

PASTE  UK,  Experiments   with  micrococci, 

45 
on  relation  of  micro-organisms 

to  septicaemia,  50 
on    causes    of  decomposition, 

88 

PAULY,  case  of  tendon-suture,  272 
P£AN,  on  forcipressure,  101 
Pelvis,  wounds  of,  369 
Pericardium,  wounds  of,  346 
Peri-neural  suture,  276 
Periphlebitis,  291 
Peritoneal  cavity,  cleansing,  367 
drainage,  367 
exploration  of,  359 
transfusion,  137 
Peritoneum,  wounds  of,  352 
Peritonitis,  358,  869 
PETIT,  J.  L.,  tourniquet  of,  123 
Pharynx,  suture  of,  337 
wounds  of,  336 
Phlebitis,  291 

PHYSICK,  on  ligatures  of  leather,  108 
PiLCHER,  J.  E.,  case  of  wound  of  internal 

jugular  vein,  292,  340 
Pin  suture,  175 
Pincetten,  compressiv-,  101 
Pine,  acupressure,  99 
PlKOGOPP,  lath-gypsum  splint,  265 
on  ligation  of  veins,  290 
Plaster,  adhesive,  162 

ichthyocolla,  163 
Plaster-of-Paris,    how  prepared  for  use, 

210 

splints,  208 

splints  in  compound  frac- 
tures, 263 

Pleura,  wounds  of,  344,  347 
Plugging  blood-vessels,  means  of,  114 
Pneumonia,  traumatic,  347 
Pneumothorax,  348 
Poisoned  wounds  defined,  10 
Poisoning  by  bismuth  subnitrate,  89 
by  carbolic  acid,  80 
by  iodoform,  86 

Polypi,  from  exuberant  granulations  pro- 
jecting into  trachea,  335 
PONFINCK,  on  peritoneal  transfusion,  137 
Position,  as  a  means  of  apposition,  160 
as  a  means  of  rest,  205 
in  arresting  haemorrhage,  119 


Position,  in   the  treatment   of  inflamma- 
tion, 225 
Potassium  iodide,  power  as  a  germicide, 

71 

permanganate,   as  an  antisep- 
tic, 76 

permanganate,  power  as  a  ger- 
micide, 71,  72 
Poultices,  225 

Practice  of  wound-treatment,  91 
Primary  haemorrhage,  285 
Primary  amputations,  377 
PRINCE,  D.,  on  bead  suture,  179 

on    continuous    submersion, 

142 
Principles  of  wound-apposition,  183 

of  wound-treatment,  1 
Probes,  253 
Probing,  253 

Protection,  defects  of,  analyzed,  28 
Protective,  the,  195 
Protrusion  of  abdominal  viscera,  353 
Ptomaines,  49 
Punctured  wounds,  245 

of  scalp,  303 
Purification  of  air,  66,  68,  156 

of  sponges,  139 
Pus,  30 

Putrefaction-producing  organisms,  42 
Pyaemia,  49 

QUILL  suture,  177 

Quinine,  power  as  a  germicide,  73 

REACTION,  21 

Rectum,  aluminated  charcoal   as  a  dress- 
ing after  extirpation  of,  84 
wounds  of,  374 
Reef-knot,  173 

Relaxation  of  vessels  in  treatment  of  in- 
flammation, 224 
of  wounded  structures  by  posi- 
.     tion,  160 
stitches,  165 

Removal  of  plaster  splints,  213 
Repair,  destructive  disturbances  of,  33 
modified  normal,  29 
normal,  power  of,  33 
of  wounds,  modifying  influences, 

12 

of  wounds  of  blood-vessels,  281 
Resolution  of  inflammation,  34 


INDEX. 


389 


Rest,  205 

after  incised  wounds,  242 
in  inflamed  wounds,  219 
Reversion  of  tissue,  embryonic,  26 
REYHER,on  exploring  gunshot  wounds,  249 
Ribs,  resection  of,  348 
RICHARDSON,  on  iodine,  84 
ROCHARD,  on  healing  of  wounds  in  hot 

climates,  17 
Roller  bandages,  161,  162 

double-headed,  for  head, 

318 

plaster-of -Paris,  211 
Roux,  on  ligation  of  veins,  290 
Rubber  bandages,  197 

in  treatment  of  inflam- 
mation, 220 
cord  tourniquet,  125 
tissue,  197 
tubing  for  water-coils,  223 

SAGITTAL  bandage,  319 

Salicylated  cotton,  185 

Salicylic  acid  as  an  antiseptic,  82 

power  as  a  germicide,  71 
power  in  restraining  germ- 

development,  72 
Sand  as  a  wound-dressing,  193 
SANDS,  H.  B.,  antiseptic  results  of,  56 
needle-holder  of,  167 
on  iodoform,  85 
on  trephining,  309,  320 
Saw-dust  as  a  wound-dressing,  194 
Scabbing,  healing  by,  30 
Scalp,  micro-organisms  infesting,  64 

wounds  of,  302,  306 
Scarifications  of  inflamed  tissues,  225 
SCHAPPS,  J.  C. ,  case  of  penetrating  gun- 
shot wound  of  abdomen,  357 
SCHEDE,  case  of  lateral  suture  of  femoral 

vein,  298 

table  of  amputations,  55 
Sciatic  nerve,  suture  of,  277 
Scrotum,  micro-organisms  infesting,  64 
Secondary  amputations,  377 
haemorrhage,  287 
suture,  Kocher's  method  of,  144 
Sepsis,  what  constitutes,  60 
Septicaemia,  49 

treatment  of,  232 
Septic  wounds  defined,  11 

how  cleansed,  157 


Serres-fines,  haemostatic,  101 

Serres-fortes,  haemostatic,  101 

SEUTIN,  plaster  shears  of,  215 

SHARPE,  on  ligatures,  106 

Shock,  21,  128 

Silk  ligatures,  how  made  aseptic,  112 

for  sutures,  167 
Silkworm-gut  ligatures,  109 

sutures,  168 
Silver  wire  sutures,  170 
SIMON,  on  suture -threads,  167 
SIMPSON,  J.  T. ,  on  acupressure,  99 
SIMPSON,  I.,  case  of  penetrating  wound  of 

abdomen,  354 
SIMS,  J.  M  ,  on  silver  wire  sutures,  170 

on        suturing        peritoneal 

wounds,  353 

on  treatment  of  gunshot 
wounds  of  peritoneal  cav- 
ity, 359 

Sinus,  wound  of  longitudinal,  313 
Sinuses,  intracranial,  wounds  of,  313 
Skin,  method  of  purifying,  154 

precautions  in  disinfecting,  65 
regions    of,    abounding    in    micro- 
organisms,  64 
Skull,  contusions  of,  308 

fractures  of,  309 
Sloughs,  32 
Sodium,   sulphite,  hypo-sulphite,    borate 

and  salicylate,  power  as  germicides,  71 
Sorbefacients,  239 
Spanish  windlass,  124 
Spleen,  protrusion  of,  355 
Splints,  206 

plastic,    in   compound    fractures, 

263 
Sponges,  139 

compressed,  in  the  treatment  of 

inflammation,  220 
Spray,  how  most  effective,  157 

producers,  156 
Sprays,  antiseptic,  67 
Spun-glass  drains,  150 
STEIN,  A.,  on  advantages  of  laparotomy  in 
intra-peritoneal  wounds  of  bladder,  372 
STEUNBERG,    G.     M. ,    experiments    with 

germicides,  results  of,  70 
STIMSON,  L.  A. ,  observations  on  antiseptic 

value  of  carbolic  spray,  67 
STOKES,  antiseptic  results  of,  56 
Stomach,  protrusion  of,  356 


390 


INDEX. 


Strangulated  intestine,  355 
STKICKEK,  on  repair  of  wounds,  25 
Styptics,  118 
Subcutaneous  effusions,  238 

haemorrhage,  237 
wounds,  237 
Sublimated  cotton,  186 

sand,  193 

Submersion,  continuous,  142 
Sulphuric  acid,  power  as  a  germicide,  71, 

73 

power  in  restraining  germ- 
development,  72 

Sulphurous  acid,  power  as  a  germicide,  73 
Sunlight,  effect  of,  on  the  wounded,  17 
Suppuration,  30 

and  micrococci,  46 
Surgical  knot,  173 
Suspension  of  splints,  213 
Suture,  bead,  179 
button,  180 
continuous,  174 
Czerny's,  363 
Emmert's,  362 
Gely's,  362 
Gussenbauer's,  363 
interrupted,  174 
invagination,  Jobert's,  364 
Jobert's,  361 
Lembert's,  360 
of  bladder,  373 
of  intestine,  360 
of  nerves,  274,  276 
of  peritoneum,  353 
of  pharynx,  337 
of  stomach,  360 
of  tendons,  271 
of  trachea,  333 
of  veins,  lateral,  298 
peri-neural,  276 
pin,  175 
quill,  177 
tubular  nerve,  278 
Sutures,  application  of,  165,  170 
aseptic,  112 
in  wounds  of  abdominal  parietes, 

352 

materials  for,  167 
removal  of,  174 
Syphonage  and  horse-hair  drains,  150 

TAMPON  of  Desault,  343,  344 


Tampons,  antiseptic,  248 
haemostatic,  98 

Teeth,  haemorrhage  after  extracting,  331 

Tenaculum,  112 

Tendo-Achilles,  suture  of,  272 

Tendon-suture,  271 

Tendons,  wounds  of,  270 

Tension,  effect  of,  28 

Thermometer,  as  a  guide  in  the  treatment 
of  wounds,  216 

THIERKY,  on  torsion,  115 

THIERSCH,  bead  suture  of,  182 
on  salicylic  acid,  82 

Thoracentesis,  348 

Thoracic  duct,  wounds  of,  344 

Thorax,  drainage  of,  349 
wounds  of,  341 

THORNTON,   KNOWSLEY,  on  drainage  of 
peritoneal  cavity,  368 

Thread  for  sutures,  167 

Through-drainage,  Markoe's  method,  153 

TIEGEL,  experiments  on  suppuration  and 
septicaemia,  45 

TILLMANS,   on    hypodermics   of    carbolic 

acid  in  erysipelas,  231 
on  suturing  nerves,  274 

Toes,  micro-organisms  infesting,  64 

Torsion,  115 

Torsion-forceps,  117 

TOURDES,  on  wounds  of  internal  mam- 
mary artery.  342 

Tourniquets,  123 

Tow,  191 

Towels,  to  be  purified,  155 

Trachea,  suture  of,  333 
wounds  of,  333 

Tracheal  canulas,  335 

Transfusion  of  blood,  129 

Traumatic  fever,  22 

TRAVERS,  B. ,  on  wounds  of  veins,  289 

Trephining,  320 

Tropical  climates,  healing  of  wounds  in, 
17 

TROUSSEAU,  on  fatal  phlebitis  after  vene- 
section, 290 

Tubes,  drainage,  145 

Tubular  drainage,  145 

nerve-suture,  278 

Turf-mould  as  a  wound-dressing,  191 
dressings  of  Esmarch,  203 

Turpentine,  haemostatic  effects  of,  97 
power  as  a  germicide,  73 


INDEX. 


391 


Turpentine,  use  in  disinfecting  skin,  65 
Twisted  suture,  175 

TYNDALL,  researches  on  causes  of  decom- 
position, 38 

ULNAR  nerve,  suture  of,  275 
Union  of  wounds,  25 

VASCULAR  relaxation,   means  of   produ- 
cing, to  relieve  inflammation,  224 
VAULAIR,  on  tubular  nerve-suture,  278 
Vein,  internal  jugular,  wounds  of,  339 
Veins,  lateral  ligation  of,  295 
lateral  suture  of,  298 
wounds  of,  288 
VELPEAU,  on  torsion,  115 
Venesection  in  head-injuries,  312 
Ventilation,  necessity  for,  18 
VERHETJIL,  on  forcipressure,  101 
Vertebral  arteries,  wounds  of,  338 
Vessels,  intra-cranial,  wounds  of,  313 
VINCENT,  on  advantages  of  laparotomy  in 
intra-peritoneal  wounds  of  bladder,  372 
VOLKMANN,  anthrax  infection   from   cat- 
gut, 78 

antiseptic  results  of,  54 
spoon-curettes  of,  158 

WALES,  P.  S. ,  on  healing  of  wounds  in  hot 

climates,  16 
WALTER,  case  of  intra-peritoneal  wound  of 

bladder,  370 

Water-coils,  in  inflammation,  223 
Water,  hot,  as  an  haemostatic,  96 
Waxed-paper,  as  a  wound- dressing,  197 
Weather,  effect  of,  on  repair  of  wounds,  16 
WEIR,  R.  F. ,  on  antiseptic  uses  of  corro- 
sive sublimate,  75 
on  deterioration  of  carbolic 

acid  dressings,  79 
WELLS,   SPENCER,  on   drainage   of  peri- 
toneal cavity,  368 
on  forcipressure,  101 
WHITE,  on  horse-hair  drains,  150 
WIGHT,  J.  S.,  artery  forceps,  117 

on  wire-gauze  splints,  207 
WILLETT,  A.,  case  of  laparotomy  for  in- 
tra-peritoneal rupture  of  bladder,  371 
Windows  in  plaster  splints,  211 
Wire-gauze  splints,  207 
WISEMAN,  R,  definition  of  wounds,  7 


Wood-wool,  as  a  wound -dressing,  194 
Wound-disinfection,  69 

disturbances  and  micro-organigms, 

58 

dressings  denned,  66 
dressings,  Lister's,  198 
secretions,  importance  of  prevent- 
ing their  accumulation,  63 
Wounds,  aseptic,  defined,  11 
classification  of,  8 
communicating  with  bone-frac- 
tures, or  opening  joint-cavities, 
255 

constitutional  effects  of,  21 
contused,  242 
definition  of,  7 
gunshot,  247 
incised,  240 
lacerated,  242 
open,  defined,  9 
open,  effects  of  inflammation  in, 

36 
of   mucous   orifices,  difficulty  in 

preserving  aseptic,  65 
of  special  regions,  299 
poisoned,  defined,  10 
septic,  defined,  11 
septic,  how  cleansed,  157 
physiology  of  repair  of,  25 
punctured,  245 
special,  235 
subcutaneous,  237 
subcutaneous  defined,  9 
suppurating,  30 

WRIGHT,  D.  F..   on  ligation  of  artery  of 
supply  in  treatment  of  inflammation,  226 
Wrist,  case  of  incised  wound  of,  241 

YOUNG,  THOS.,  on  ligatures  of  catgut,  108 

ZAUN,    experiments   on    suppuration   and 

septicaemia,  45 
ZETS,  effects  of  immersion  of  wounds  in 

warm  water,  143 
Zinc,  chloride  of,  as  an  antiseptic,  81 

power  as  an  application 
to  septic  wounds,  159 
power  as  a  germicide,  71 
sulphate,  power  as  a  germicide,  71 
ZWEIFEL,  anthrax  infection  from  catgnt, 
78 


Date  Due 


CAT.    NO      ?3    233  PRINTED    IN    U.S.A. 


000411706 


Pilcher,  Lewis  S 

Treatment  of  wounds 


WO  TOO 

P637t 

1883 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


